massachusetts laborers’ health and welfare fund...delta dental— questions about dental beneﬁ...

A Summary of Plan Features

Massachusetts Laborers’Health and Welfare Fund

i | Massachusetts Laborers’ Health and Welfare Fund

Foreign Language Notice

Este folleto contiene un resumen en inglés de sus derechos y benefi cios del Plan bajo el Massachusetts

Laborers’ Health and Welfare Fund (Fondo de Salud y Bienestar de Massachusetts Laborers). Si usted tiene

difi cultad para entender cualquier parte de este folleto, comuníquese con la Ofi cina del Fondo en 14 New

England Executive Park, Burlington, MA 01803-0900, o llame al 781-272-1000. Las horas de ofi cina son de

8:30 A.M. a 4:30 P.M., lunes a viernes.

Este livreto contém um sumário em idioma inglês dos direitos e benef ícios do seu Plano, segundo o

Massachusetts Laborers’ Health and Welfare Fund (Fundo de Saúde e Bem-estar dos Trabalhadores do

Massachusetts). Caso tenha difi culdade para compreender qualquer parte do presente livreto, contate o

Escritório do Fundo, no endereço: 14 New England Executive Park, Burlington, MA 01803-0900, ou ligue

para o número: 781-272-1000. O horário de funcionamento do escritório é: das 8:30 às 4:30.

Massachusetts Laborers’Health and Welfare Fund

14 New England Executive Park

Suite 200

P.O. Box 4000

Burlington, MA 01803-0900

Telephone: 781-272-1000

Toll-Free Telephone: 800-342-3792

Fax: 781-238-0703

Online: www.MLBF.org

Th is booklet is your Summary Plan

Description (SPD) of the Plan. Th e

SPD is intended to explain the major

provisions of the Plan in simplifi ed

language.

Date of Th is Edition

Th e information in this SPD is based on the Plan rules in eff ect as of January 1, 2008.

Union Trustees Louis A. Mandarini, Jr., ChairmanJoseph Bonfi glio, Co-ChairmanThomas TroyDouglas J. Watson

Employer Trustees John A. Farina, Secretary-TreasurerRichard McCourt, Co-Secretary-TreasurerThomas J. GunningWilliam Sullivan

Executive Director Thomas P.V. Masiello

Operations

Manager

Ronald A. Doyle

Co-Counsel to the

Health and Welfare

Fund

Corrente Law Corporation;O’Reilly, Grosso and Gross

Consultants and

Actuaries

The Segal Company

Fund Auditors Saslow, Lufkin & Buggy

A Summary of Plan Features | ii

January 1, 2008

Massachusetts Laborers’ Health and Welfare Fund14 New England Executive ParkSuite 200, P.O. Box 4000Burlington, MA 01803-0900781-272-1000 or 800-342-3792Fax: 781-238-0703www.MLBF.org

We are pleased to present you with this new Summary Plan Description (SPD) of your benefi ts under the Massachusetts Laborers’ Health and Welfare Fund.

Th is new edition has been prepared to make it easy for you to fi nd the information you need about your benefi ts. Here are some of its features:

A “Contacts” chart for quick reference (see page iii);

An overview of the benefi ts available (see page 1);

“Fast Facts” at the beginning of each chapter to give you a broad sense of what’s contained within the section; and

A chapter on life events (adding a dependent to your family, absence from employment for military service, etc.) that may involve your benefi ts.

While we are committed to providing health care benefi ts that include treatment of illnesses, we cannot stress too strongly how important it is for all of us to take charge of our health. One way to do that is to take advantage of the “wellness” benefi ts that are included in your benefi ts program:

Annual physical exams;

Prenatal care and assistance managing the risks of pregnancy;

Aff ordable prescription drugs for conditions requiring medications;

A Member Assistance Program to help you deal with the problems of life;

Preventive dental care—oral exams, x-rays, and cleanings and, for children, fl uoride treatment, sealants, and space maintainers; and

Comprehensive eye exams.

As you read the rest of this summary, you will see the above items discussed in more detail. You should familiarize yourself with each of these programs to maximize the benefi ts available to you and your family.

Questions?

Please read this SPD carefully and keep it handy for future reference. If you are covering dependents under the Plan, please share the information in the SPD with them. If you have any questions about the Plan after reading this SPD, please contact the Fund Offi ce at the address or telephone numbers above or visit our Web site at www.MLBF.org.

Sincerely,

BOARD OF TRUSTEES

•••

•

•••••

•

iii | Massachusetts Laborers’ Health and Welfare Fund

Contacts

The Fund Offi ce—www.MLBF.org

To help you with your questions about: eligibility information, claims assistance, or COBRA

781-272-1000 or800-342-3792

BlueCross BlueShield—www.BCBS.com

Help in fi nding PPO providers for medical Plan services, preferred providers for home health care and durable medical equipment, and assistance managing the risks of pregnancy and obtaining required pre-authorizations.

To locate aPPO Provider:800-810-2583

Pre-authorizations: 800-327-6716

The Wellness Corporation

Member Assistance Program (MAP)—Required pre-authorizations for treatment of mental health conditions, alcoholism, and substance abuse

• 800-522-6763

Complementary Medicine—Required pre-authorizations for massage therapy, oriental medicine, biofeedback, homeopathy, nutrition and naturopathy

• 800-522-6763

Express Scripts—www.express-scripts.com

Help in fi nding a network pharmacy• 800-467-2006

Mail-order prescription service• 800-233-7139

If pre-authorizations are required for certain drugs, have your physician call800-417-8164 or send a fax to 800-357-9577

•

Delta Dental—www.deltamass.com

Questions about dental benefi ts and assistance fi nding participating dentists

800-872-0500 or 617-886-1234

Davis Vision—www.davisvision.com

Questions about vision benefi ts and assistance fi nding network providers

800-999-5431

A Summary of Plan Features | iv

Contents

Overview of the Available Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Benefi ts for Retirees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Eligibility for Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

When Your Participation Begins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Continuing Your Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Reciprocity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Dependent Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

If You Enter Military Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Retiree Eligibility for Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

COBRA Continuation of Health Care Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

COBRA Continuation Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Medical Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Th e Plan Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Lifetime Maximum for Benefi t Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Preferred Provider Organization (PPO) Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Required Pre-Authorizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

What the Plan Covers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Extension of Medical Benefi ts in Case of Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Filing a Claim for Medical Plan Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Prescription Drug Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Use of Retail Pharmacies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Using the Mail-Order Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25


Th e Preferred Medication List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25


Step Th erapy Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Exclusions from Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Filing a Claim for Prescription Drug Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Member Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27


Claims for Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Dental Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

v | Massachusetts Laborers’ Health and Welfare Fund


Covered Services—Limits and Restrictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Participating Dentists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Pre-Treatment Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30


Filing a Claim for Dental Benefi ts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Vision Care Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

How the Plan Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31


Using a Davis Vision Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Th e Optional Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32


Filing a Claim for Vision Care Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Weekly Accident and Sickness Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

Eligibility for Payment of Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

When Payment of Benefi ts Starts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

How Long Payments Can Continue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

Limits and Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

Filing a Claim for Weekly Accident and Sickness Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

Life Insurance Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Your Benefi ciary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

If You Become Totally and Permanent Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Extended Death Benefi t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Conversion Privileges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Filing a Claim for Life Insurance Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Accidental Death and Dismemberment Benefi ts (AD&D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

How the Benefi ts Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Your Benefi ciary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Limits and Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Filing a Claim for Accident Death and Dismemberment (AD&D) Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . .35

Retiree Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Th e Retiree’s Self-Pay Medical Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Retiree Vision Care & Hearing Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Retiree Death Benefi t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Life Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

If You Get Married . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

If You Add a Child to Your Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

If You Divorce or Legally Separate from Your Spouse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

If a Child Loses Eligibility for Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

A Summary of Plan Features | vi

If You Enter Military Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

If You Move . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

If You Become Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

If Your Eligibility Ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

In the Event of Your Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

Coordination of Benefi ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

How Coordination of Benefi ts Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Which Plan Pays First . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Coordination with Other Funds Under Reciprocal Arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

Coordination with Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

Th e Fund’s Right to Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

Reimbursement and Subrogation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

Qualifi ed Medical Child Support Orders (QMCSOs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

General Limits and Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

Plan Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

Collective Bargaining Agreements/Employer Contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

Organizations Th rough Which Benefi ts Are Provided . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

No Liability for Practice of Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

Your ERISA Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

Appendix A: Privacy of Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

Section 1: Purpose of Th is Notice and Eff ective Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

Section 2: Your Protected Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

Section 3: Your Individual Privacy Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

Section 4: Th e Fund’s Duties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

Section 5: Your Right to File a Complaint with the Fund or the HHS Secretary . . . . . . . . . . . . . . . . . . . . . .56

Section 6: If You Need More Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

Section 7: Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

Appendix B: Claims and Appeals Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Use of an Authorized Representative. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Types of Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Filing a Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

When Claims Must Be Filed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

Timing of Initial Claims Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

Notice of a Denied Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

Appeal Process for Denied Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

Timing of Notice of Decision on Appeal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

Limitation on When a Lawsuit May be Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

Appendix C: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

Th e Board of Trustees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . back cover

1 | Massachusetts Laborers’ Health and Welfare Fund

Overview of the Available Benefi ts

Th e benefi ts available to active participants and their dependents are summarized in the chart below.

Benefi ts for Retirees

Th e Fund off ers the following benefi ts for qualifi ed retirees and their eligible dependents:

A self-pay medical and dental plan; and

A death benefi t in the event of the qualifi ed retiree’s death.

••

Medical Benefi ts for a wide array of services, from hospital and physician services to durable medical equipment. A network provider feature can help you keep your share of the costs down.

Prescription drugs Covers generic and brand-name prescription drugs after you pay $5, $15, or $25 per prescription at retail pharmacies. Also offers a mail-order service for maintenance drugs at a reduced cost, with copayments.

Member Assistance

Program

Assistance with personal and family diffi culties, mental health-related conditions, alcoholism and substance abuse.

Dental Benefi ts for preventive care (exams, cleanings, etc.). Plan A also includes basic and major restorative care (from fi llings to dentures) and orthodontia benefi ts for children under age 19. A network provider feature can help you keep your share of the costs down.

Vision care Benefi ts for an eye exam, spectacle lenses, and a frame once every 24 months (once every 12 months for children under age 19) if you use a Davis network provider. If you use a network provider, you can keep your share of the costs down.

Hearing device $800 for a hearing device per ear, once every fi ve years.

Weekly accident and

sickness

(for members only)

Pays a weekly income-replacement benefi t of up to $273 when illness or injury prevents you from working. Benefi ts start on 1st day of disability if the disability is caused by an accident or on the 8th day of disability if the disability is caused by an illness and can be paid for up to 13 weeks.

Life insurance

(for members only)Pays $10,000 to your benefi ciary in the event of your death.

Accidental death

and dismemberment

(for members only)

Pays another $10,000 to your benefi ciary if you should die from an accident. It pays up to $10,000 to you if you lose limbs or sight in an accident.

A Summary of Plan Features | 2

number of hours you work in covered employment. As of January 1, 2007, there are two benefi t plans available for active members—Plan A or Plan B.

Your eligibility to participate in Plan A or Plan B for each 6-month Eligibility Period will depend on the number of recorded hours of employment you accumulate with one or more contributing employers within a period of 12 consecutive months.

Eligibility Requirements

Plan A—1,000 recorded hours within a12-month Qualifying Period = coverageduring a 6-month Eligibility Period

Plan B—700 recorded hours within a12-month Qualifying Period = coverageduring a 6-month Eligibility Period

•

•

Eligibility for Coverage

Th is section explains the rules that governparticipation in the Plan.

FAST FACTS:

Th e number of hours you work in covered employment determines your eligibility forPlan A or Plan B.

Plan A—1,000 recorded hours within a12-month Qualifying Period = coverageduring a 6-month Eligibility Period

Plan B—700 recorded hours within a12-month Qualifying Period = coverageduring a 6-month Eligibility Period

When Your Participation BeginsYou are eligible to participate in the Massachusetts Laborers’ Health and Welfare Plan based on the

•

–

–

12-Month Qualifying Period

Collection Lag for Employer Contributions 6-Month Eligibility Period

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

FIRST QUALIFYING PERIOD REQUIREMENT FOR JANUARY THROUGH JUNE ELIGIBILITY PERIOD

12-Month Qualifying Period

Collection Lag for Employer Contributions 6-Month Eligibility Period

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Example:

Your eligibility during the 6-month Eligibility Period beginning January 1, 2008 will depend on the numberof recorded hours of employment you accumulated during the 12-month Qualifying Period beginning on October 1, 2006, and ending on September 30, 2007. If you work 1,000 or more hours, you will be eligible for Plan A. If you work 700 hours, but fewer than 1,000 hours, you will be eligible for Plan B.

ABSENCES FROM EMPLOYMENT

See “Life Events,” starting on page 37, for information on how military service or an absence under the Family and Medical Leave Act will affect benefi ts coverage.

SECOND QUALIFYING PERIOD REQUIREMENT FOR JULY THROUGH DECEMBER ELIGIBILITY

Continuing Your EligibilityOnce you meet the eligibility requirements for either Plan A or Plan B, your participation will continue as long as you work at least 1,000 hours for Plan A or 700 hours for Plan B in a 12-month Qualifying Period for the next 6-month Eligibility Period. Your dependents’ participation will end when your coverage does or, if earlier, when they no longer meet the eligibility requirements.


ReciprocityAfter June 30, 2005, should you work in Rhode Island or Connecticut, any contributions remitted to the Rhode Island or Connecticut Funds will be reciprocated back to the Massachusetts Laborers’ Fund on your behalf, provided you are a member of a Maine, New Hampshire, Vermont or Massachusetts Local Union.

In order to have contributions exchanged in a timely manner, whenever you work outside the states of Maine, Massachusetts, New Hampshire and Vermont you must contact the Fund Offi ce.

Should you wish contributions for your work in Rhode Island or Connecticut to stay with those Funds, you have the option to elect not to have your contributions reciprocated. You should either contact the Fund Offi ce in the state where you are working to advise them you do not authorize the transfer of contributions to your Home Fund in Massachusetts or contact the Massachu-setts Fund Offi ce to obtain a form that will permit you to elect not to have your contributions transferred. You can only make one election per twelve-month period.

Please be aware that amounts you pay toward deductibles under the health care plans are nottransferable between funds.

You may not receive benefi ts from more than one Laborers’ fund in New England at the same time. However, if you have elected not to transfer the contributions to Massachusetts and are entitled to benefi ts under more than one Laborers’ fund, the benefi ts will be coordinated. See “Coordination of Benefi ts” on page 40 for more information.

Dependent EligibilityYour dependents’ eligibility will start when your eligibility starts or, if later, on the date they become your qualifi ed dependents (see “Frequently Asked Questions” on page 10). You may cover the following dependents under the Plan’s health care benefi ts:

the spouse to whom you are legally married (including a spouse who is the same gender as you, if the state where you live allows you to legally marry each other);

your unmarried children under 19 years of age; and

your unmarried children over 19 years of age, but less than 23 years of age, who are enrolled as full-time students in an accredited school, college, or university and who are dependent on you for fi nancial support. Student verifi cation must

•

•

•

be provided to the Fund Offi ce each semester to confi rm full-time status and continuity of attendance. (Orthodontia benefi ts are available only for dependent children up to 19 years of age.)

Please note that you will be responsible for reimbursing the Fund for claims paid if your depen-dent child fails to maintain full-time student status.

“Children” include natural children, legally adopted children, children placed with you for adoption, and children, including step children, for whom you have legal guardianship.

In order for the Plan to consider a child an eligible dependent, the child must have the same principal place of abode as you for over half of the year, and must be dependent on you for over half of their support. Proof that you provide over half of their support must be furnished to the Plan upon request.

Th e requirements that you provide over half of the child’s support, and that the child have the same principal abode as you for over half of the year will not apply if: (i) you and the child’s other parent are divorced or legally separated under a decree of divorce or separate maintenance, separated under a written separation agreement, or live apart at all times during the last six (6) months of the calendar year; (ii) you and the child’s other parent provide over half of the child’s support; and (iii) the child is in the custody of one or both parents for more than half of the calendar year.

If a child for whom you are the legal guardian is not related to you (in the manner described in Section 152(d)(2)(A) through (G) of the Internal Revenue Code), he or she must have the same principal place of abode as you for the entire year and must be considered a member of your household.

Disabled Children

You may be able to cover a disabled child beyond the age he or she would otherwise lose eligibility. To do so, you will need to provide the Fund with proof that the child is mentally or physically handicapped, so as to be incapable of earning his own living, and is dependent upon you for over half of their support.

CHANGES IN DEPENDENT ELIGIBILITY

You are responsible for notifying the Fund Offi ceif a dependent ceases to be eligible for coverage.


You will need to provide this proof before or within 31 days after the child reaches the age where coverage would otherwise terminate. Medical proof of handicapped status must be provided annually or as requested by the Trustees. Th e child’s exemption from the age requirement can continue for as long as his or her incapacity continues.

Same-Sex Spouses

You may cover a spouse who is the same gender as you if the state where you live allows you to legally marry each other. You may also cover such a spouse’s eligible dependent children provided that such dependent children meet the defi nition of eligible dependent(s) identifi ed on page 3 under Dependent Eligibility. As part of the enrollment process, you will need to submit a marriage certifi cate to the Fund, as well as birth certifi cates, adoption documents or legal guardianship documents for any qualifi ed dependent children.

Taxes on Coverage of Same-Sex Spouses

Federal law requires that you pay Federal income and FICA (Social Security and Medicare) taxes on the value of the coverage provided to your same-sex spouse (and his or her eligible dependent children, if applicable). You will need to send a payment for each eligibility period to the Fund—for transmission to the IRS—in advance of your spouse’s receiving coverage. Th e Fund Offi ce will notify you of the amount due. If you are a Fund Offi ce employee, payment of these taxes will be withheld from your pay.

If You Enter Military ServiceIf you enter active qualifi ed military service in the uniformed services of the United States while eligible for Fund coverage, you and your eligible dependents can continue to be covered during your active military service.

For this to happen, you must submit a copy of your military induction orders to the Fund Offi ce upon entering active military service.

Your eligible dependents will continue to be covered as long as they continue to meet the Plan’s defi nition of “dependent” (see page 3). Your dependents may also be eligible for military health coverage called TRICARE; if so, the Fund will coordinate its benefi ts with TRICARE.

Continued coverage under the Fund will NOT include:

coverage for any illness or injury determined by the Secretary of Veterans Aff airs to have been

•

incurred in or aggravated during performance of service in the uniformed services (the uniformed services and the Department of Veterans Aff airs will provide care for service-connected disabilities);

weekly accident and sickness benefi ts; or

life insurance or accidental death and dismemberment benefi ts, if the loss is caused directly or indirectly, in whole or in part, by a war or an act of war.

When you are honorably discharged from “service in the uniformed services,” or have discharge orders from active duty or a DD Form 214, the eligibility that you had remaining under Plan A or Plan B prior to entering military service will be reinstated, or if greater, six months of eligibility will be allowed, provided that you report back to work or apply for reemployment within the time frame allowed by law, as outlined in the accompanying chart.

Th e Plan provisions that apply if you enter military service comply with the requirements of the Uniformed Services Employment and Reemploy-ment Rights Act (USERRA) and, in some respects, provide more than what USERRA requires.

TIME FRAME FOR RETURNING TOWORK AFTER MILITARY SERVICE

If you are hospitalized or convalescing from an injury caused by active duty, these time limits can be extended for up to two years.

Make sure you adhere to the provisions for returningto covered employment after your military service ends.

Retiree Eligibility for Benefi tsYou may be eligible for continuing medical and dental benefi ts after you retire, and your benefi ciary may be eligible for a death benefi t if you die after retiring.

See “Retiree Benefi ts” on page 36 for more information.

••

Length ofMilitary Service Reemployment Deadline

Less than 31 days At the beginning of the fi rst full regularly scheduled working period on the fi rst calendar day following discharge (allowing travel time plus eight hours)

31 through 180 days Within 14 days after discharge

More than 180 days Within 90 days after discharge or as otherwise required by law


COBRA Continuation of Health Care Coverage

COBRA provides an option for temporarily

continuing coverage under Plan A or Plan B if you

lose eligibility.

FAST FACTS:

You will lose eligibility for coverage as an active participant if you are short work hours during a qualifying period or retire.

Your dependents will lose eligibility when you do. Th ey can also lose eligibility earlier, for other reasons.

Depending on the reason for the loss of eligibility, you or your dependents could continue health care coverage under COBRA for 18 – 36 months.

You will pay the full cost of your COBRA continuation coverage.

•

•

•

•

COBRA Continuation CoverageYou and your eligible dependents have the right to

continue your health care coverage (medical, dental,

and vision) under this Plan on a self-pay basis if

coverage would otherwise terminate because of a

qualifying event. Th is provision does not apply to

life insurance, accidental death and dismemberment

benefi ts, weekly accident and sickness benefi ts, or

extended medical benefi ts for a disability.

Qualifying events are shown in the accompanying

chart. You may continue only the health care

coverage (under Plan A or Plan B) that was in

eff ect at the time of the qualifying event. Th e only

exception is if your qualifying event is retirement on

or after January 1, 2007 (see page 7).

COBRA CONTINUATION COVERAGE

COBRA Qualifying Event Who May Continue Benefi ts

Maximum Period of Continuation

Coverage

You lose eligibility due toworking less than 1,000 hours in a 12-month Qualifying Period (for Plan A) or 700 hours in a 12-month Qualifying Period (for Plan B) retirement

•

•

You, your spouse, and/or your dependent children covered under the Plan

18 months*

You die Your spouse and/or your dependent children covered under the Plan

36 months

You divorce or legally separate from your spouse Your former spouse and/or your dependent children covered under the Plan

36 months**

Your child ceases to meet the Plan’s defi nition of an eligible dependent (for example, because of marriage or a change in age or student status)

The affected dependent child who was covered under the Plan

36 months

You become entitled to Medicare (Under Part A, Part B, or both)

Your spouse and/or your dependent children covered under the Plan

36 months

* Disability extension: Coverage for all enrolled family members may be continued an additional 11 months (for a total of 29 months) if you or a covered dependent becomes totally disabled before or during the fi rst 60 days of COBRA continuation coverage. See “Extended COBRA Period for Disability” later in this section.

** See the description of “Continuation Coverage Rights because of divorce or legal separation” on page 8.

Effect of prior Medicare enrollment: If the shortage of hours or retirement occurs less than 18 months after the date you become entitled to Medicare (Part A, Part B, or both), the maximum period of continuation coverage for your dependents covered under the Plan will be 36 months after the date of your Medicare entitlement.

Qualifi ed Benefi ciaries

Under the law, only “qualifi ed benefi ciaries” are entitled to COBRA continuation coverage. A qualifi ed benefi ciary is any individual who was

covered under the Plan on the day before the COBRA qualifying event by virtue of being a participant on that day, the spouse of a participant, or the dependent child of a participant. Same-


sex spouses have the same continuation rights as opposite-sex spouses do under COBRA.

A child who becomes a dependent child by birth, adoption, placement for adoption, or legal-guardian appointment during a period of COBRAcontinuation coverage and is enrolled within 31 days is also a qualifi ed benefi ciary and will have the same COBRA rights as a spouse or children who were covered by the Plan before the qualifying event that triggered the COBRA continuation coverage.

A spouse who becomes your spouse during a period of COBRA continuation coverage may be added to your coverage during the period you remain eligible for COBRA continuation coverage. (See “Special COBRA Enrollment Rights” later in this section.) However, such a new spouse would not be a qualifi ed benefi ciary (in other words, would not have any independent enrollment rights or be eligible for additional months of coverage if one of the “second qualifying events” described below occurred).

Extended COBRA Period for Disability

If you lose eligibility because of a shortage of hours or retirement and you or one of your covered dependents is determined by the Social Security Administration to have been totally disabled at the time of the qualifying event or within 60 days of the qualifying event, coverage may be extended for you and all enrolled dependents beyond the original 18 months up to 29 months.

See the “Member Notifi cation Responsibilities”section for information on procedures andtime frames for notifying the Fund Offi ce of Social Security Administration determinations.

Please note that the premium for the additional 11 months can be approximately 50% higher than the initial 18-month COBRA premium.

If a Second COBRA Qualifying Event Occurs

If your dependents are in an 18-month COBRA continuation coverage period because of your shortage of hours or retirement (or a 29-month period, in the case of disability) and one of the following qualifying events occurs, the maximum COBRA continuation period for your dependents will switch to 36 months (provided you and/or your dependents notify the Fund Offi ce of the second qualifying event within the time frame discussed in “Member Notifi cation Responsibilities” below):

you get divorced or legally separate;•

you die; or

your child ceases to meet the Plan’s defi nition of an eligible dependent (in this case, only the child may extend coverage).

Participants are not entitled to COBRA continuation coverage for more than a total of 18 months (unless you are entitled to an additional 11 months’ continua-tion coverage because of a disability). Even if you experience a shortage of hours followed by retirement, the retirement is not treated as a second qualifying event and you may not extend your coverage.

Member Notifi cation Responsibilities

You and/or your dependents are responsible for providing the Fund Offi ce with timely notice of the following qualifying events:

Qualifying Event Notifi cation Deadline

1. Your divorce or legal separation*

2. A child no longer qualifi es as a “dependent child”

3. A second qualifying event

4. A qualifi ed benefi ciary is determined to be disabled by the Social Security Administration

5. Determination by the Social Security Administration that the qualifi ed benefi ciary is no longer disabled

For events 1–3: No later than 60 days after the later of (1) the date of the relevant qualifying event or (2) the date on which coverage would be lost under the Plan as a result of the qualifying event.For event 4: No later than 60 days after the latest of: the date of the disability determination by the Social Security Administration; the date on which the qualifying event occurs; or the date on which the individual loses (or would lose) coverage under the Plan as a result of the qualifying event, and before the end of the fi rst 18 months of continuation coverage.For event 5: No later than 30 days after the date of the Social Security Administration determination that the qualifi ed benefi ciary is no longer disabled.

* Note: see the “Continuation Coverage Because of Divorce or Legal Separation” section on page 8.

••

For example:

Tom stops working (the fi rst COBRA qualifying event) and enrolls himself and his family in COBRA continuation coverage for 18 months. Th ree months after his COBRA continuation coverage begins, Tom’s child turns 19 and no longer qualifi es as a dependent child under the Plan’s defi nition. Tom’s child can continue COBRA coverage for an additional 33 months, for a total of 36 months of COBRA continuation coverage.


You must make sure that the Fund Offi ce is notifi ed of any of the occurrences listed in the previous table. Failure to provide this notice within the form and time frames described may prevent you and/or your dependents from obtaining or extending COBRA coverage.

Th e Fund Offi ce will notify you of your right to choose continuation coverage within 60 days of receiving notifi cation of a qualifying event. Th is notice will be sent to your last address on fi le at the Fund Offi ce. A notice will be sent to an eligible dependent at an address that is diff erent from the member’s address only if a diff erent address has been provided to the Fund Offi ce.

How to Provide Notice to the Fund Offi ce

To provide the Fund Offi ce with notice of any of these fi ve qualifying events, you must request a COBRA application form. You can obtain a copy of the form by contacting the Fund Offi ce or by visiting our Web site at www.MLBF.org. No other form of notice will be accepted by the Fund. If you have any questions about how to fi ll out this form, please contact the Fund Offi ce at 781-272-1000 or 800-342-3792.

Where to Send the Notice

Notice should be sent by U.S. mail to the following address:

COBRA DepartmentMassachusetts Laborers’ Health and Welfare Fund14 New England Executive Park, Suite 200P.O. Box 4000Burlington, MA 01803-0900

Please keep a copy, for your records, of any notices you send to the Fund Offi ce.

Who Can Provide Notice

Notice may be provided by the qualifi ed benefi ciary with respect to the qualifying event (you or your dependents, as applicable) or any representative acting on behalf of the qualifi ed benefi ciary.

Notice from one individual will satisfy the notice requirement for all related qualifi ed benefi ciaries aff ected by the same qualifying event. For example, if you, your spouse, and your child are all covered by the Plan and your child ceases to be a dependent under the plan, a single notice sent by you or your spouse would satisfy this requirement.

If you or your dependents send a notice to the Fund Offi ce as described above and the Fund Offi ce determines that you are not entitled to COBRA continuation coverage, the Fund Offi ce will send

you a written notice stating the reason why you are not eligible for COBRA continuation coverage. Th is will be provided within 14 days after the Fund Offi ce receives your notice.

Fund Offi ce Notifi cation Responsibilities

When the qualifying event is the loss of eligibility (due to working less than 1,000 hours (Plan A) or 700 hours (Plan B) in a 12-month Qualifying Period or retirement), the death of the member or the member becoming entitled to Medicare benefi ts (under Part A, Part B, or both), the Fund will determine when a qualifying event has occurred. For the other qualifying events listed on page 6, you must notify the Fund Offi ce.

Electing Coverage

Th e COBRA continuation coverage you are able to elect will be based on the coverage you were eligible for at the time of your qualifying event (excluding retirement, see below) as follows:

If you had coverage under Plan A, and you are not eligible for Plan B at the time of your loss of eligibility, the Fund will extend Plan A COBRA continuation rights.

If you had coverage under Plan B, the Fund will extend Plan B COBRA continuation rights.

If your qualifying event is retirement under the Massachusetts Laborers’ Pension Fund, on or after January 1, 2007, you will have the ability to elect either Plan A COBRA or Plan B COBRA continua-tion coverage for you and your eligible dependents regardless of the coverage you had before retirement.

You and/or your covered dependents have 60 days to make your COBRA election from the later of:

the date you would have lost coverage because of the qualifying event; or

the date you received the election form and COBRA information from the Fund Offi ce.

Participants may elect one of the following types of coverage under Plan A COBRA or Plan B COBRA:

1. Core only;2. Core plus dental; or3. Core plus dental and vision.

Each qualifi ed benefi ciary with respect to a particular qualifying event has an independent right to elect COBRA continuation coverage. For example, both you and your spouse may elect COBRA continuation coverage, or only one of you may elect COBRA continuation coverage.

•

•

•

•


A parent or legal guardian may elect COBRA continuation coverage for a minor child. If you or your spouse elects COBRA continuation coverage, you will be deemed to be electing it for your eligible dependent children as well, unless you specify otherwise in the election. If you and your spouse do not elect COBRA continuation coverage, your dependent children will be able to elect it or reject it independently of your rejection.

If you and/or your dependents do not elect COBRA within the 60-day period allowed, you will forfeit all rights to COBRA continuation coverage and your health care coverage will end.

In considering whether to elect COBRA continua-tion coverage, you should take into account that a failure to continue your group health coverage will aff ect your future rights under Federal law:

First, if you have a gap in health coverage of 63 days or more, you can lose the right to avoid having pre-existing condition exclusions applied to you by other group health plans (election of COBRA continuation coverage may prevent such a gap).

Second, if you do not get continuation coverage for the maximum time available to you, you will lose the guaranteed right to purchase individual health insurance policies that do not impose such pre-existing condition exclusions.

Finally, you have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer). Special enrollment under this provision is allowed within 30 days after your group health coverage ends because of the qualifying events listed on page 5 or at the end of COBRA continuation coverage if you get COBRA continuation coverage for the maximum time available to you.

You do not have to show that you are insurable to choose COBRA coverage.

You may not elect any coverage you did not have immediately before the qualifying event, unless you retire under the Massachusetts Laborers’ Pension Fund. See Electing Coverage on page 7.

•

•

•

Your initial continuation coverage will be identical to coverage provided to similarly situated individuals under the Plan on the day prior to the qualifying event. If benefi ts change for active participants, your coverage will change as well.

Cost of Continuation Coverage

COBRA continuation coverage is available only at your own expense. If you elect continuation coverage, you will be charged the full cost to the Plan, plus an administrative charge.

Premiums are approximately 50 percent higher during a disability extension (see “Extended COBRA Period for Disability” earlier in this section).

Sending in Payment

You must send your fi rst payment within 45 days following submission of the COBRA election form. Th is initial payment must include the cost of coverage retroactive to the fi rst day your coverage would have otherwise terminated.

Your subsequent payments must be made within 30 days after the fi rst of the month in which coverage is provided.

Continuation Coverage Because of Divorce or Legal Separation

Continuation coverage is extended to an ex-spouse without regard to COBRA continuation coverage because the Fund has chosen to follow continua-tion coverage provisions based on those described in Massachusetts law. Such alternative coverage may aff ect the duration of the maximum COBRA coverage period.

Specifi cally, if your spouse’s coverage terminates because of a divorce or legal separation, your former spouse may continue coverage under this Plan, unless the court decree provides otherwise. However, a former spouse’s coverage will terminate on the earlier of:

60-DAY DEADLINE FOR ELECTING COVERAGE

If you do not elect COBRA continuation coverage within the 60 days allowed, you will forfeit your right to COBRA continuation coverage.

PAYING YOUR COBRA PREMIUMS

Payments must be made continuously and without interruption. Failure to make the monthly payment when due will result in the termination of your health coverage. Retroactive payments will not be permitted under any circumstances.


1. the date your coverage under this Plan

terminates:

2. the date of either your or your former spouse’s

remarriage; or

3. at such time as provided by the court decree.

YOU MUST INFORM THE FUND OFFICE IF YOU

OR YOUR FORMER SPOUSE REMARRIES.

If a member’s ex-spouse loses his or her coverage

under the Plan because of any of the three reasons

above within 36 months after the parties’ divorce,

the ex-spouse may maintain COBRA continuation

coverage for the remainder, if any, of the 36-month

period that began on the date of divorce. In no case

is the ex-spouse entitled to COBRA continuation

coverage for more than the remainder, if any, of the

36-month period that began on the date of divorce.

Special COBRA Enrollment Rights

Special enrollment for the balance of your COBRA

period is also allowed for dependents who lose other

coverage. For this to occur,

your dependent must have been eligible for

COBRA coverage on the date of the qualifying

event but declined when enrollment was

previously off ered because he or she had coverage

under another group health plan or had other

health insurance coverage;

your dependent must exhaust the other coverage,

lose eligibility for it, or lose employer contribu-

tions to it; and

you must enroll that dependent by sending an

enrollment form to the Fund Offi ce within 31 days

after the termination of the other coverage or

contributions.

Adding a spouse or dependent child may cause an

increase in the amount you must pay for COBRA

continuation coverage.

Termination of COBRA Continuation Coverage

COBRA continuation coverage will end on the fi rst

of the following dates:

the date the 18-, 29-, or 36-month maximum

•

•

•

•

continuation period expires;

the date the required premium is due and unpaid

after the applicable grace period;

the date the person receiving the coverage

becomes covered under any other group medical

plan (unless the other group health plan will not

cover or limits coverage for a pre-existing health

condition of that person);

the date the person receiving the coverage

becomes entitled to Medicare benefi ts;

the date the Plan terminates; or

(for participants under the 11-month disability

extension) the date the Social Security

Administration determines that an individual on

extended disability coverage is no longer disabled

(this applies only to the 19th through 29th month

of disability extended coverage).

If COBRA continuation coverage is terminated

before the end of the maximum continuation period,

the Fund Offi ce will send you a written notice as

soon as practicable following its determination that

COBRA continuation coverage will terminate. Th e

notice will set out the reason COBRA continuation

coverage will be terminated early and the date of

termination.

Questions About COBRA?

If you have any questions regarding COBRA

continuation coverage, please contact the COBRA

Department at the Massachusetts Laborers’ Health

and Welfare Fund, 14 New England Executive Park,

Suite 200, P.O. Box 4000, Burlington, MA 01803-

0900; telephone 781-272-1000 or 800-342-3792.

If you change your marital status or add new

dependents, or if you or your spouse or other

dependents change addresses, please notify the

Fund Offi ce immediately.

•

•

•

••

RETIREE MEDICAL PROGRAM

If your qualifying event was retirement and you enrolled in COBRA continuation coverage, you may be eligible for further continuation of your coverage under the Retirees’ Self-Pay Medical Program. See page 36.


Certifi cate of Creditable Coverage

When your medical, dental, and vision coverage ends, the Fund Offi ce will provide you and/or your eligible dependents with a certifi cate of coverage that indicates the period of time you were eligible under the Plan.

If you become eligible for coverage under another group health plan or buy a health insurance policy within 62 days after your coverage under this Plan ends, the certifi cate you receive from the Fund

RESPONSIBILITY FOR CONTINUING COVERAGE

The Fund assumes no responsibility or liability if you allow your coverage to terminate. If you have any reason to believe that your eligibility will or has terminated, it is your responsibility to contact the Fund Offi ce to verify your eligibility status.

Frequently Asked Questions

Do I need to do anything to enroll in the Plan?

Yes, you will need to complete an enrollment form to provide information about yoursinformation about yourself and your dependents. Copies of your marriage certifi cate, children’s birth certifi cates or adoption rth certifi cates or adoption documents, or legal guardianship documents will also be required. You also need to designate a benefi ciary for your life insurance and Accidental Death and Dismemberment benefi ts.

If you will be covering a same-sex spouse, you will also need to send paypayments for the tax due on the value of the coverage (see page 4).

If you acquire new dependents after enrolling (for example, you get married, have a child, have legald, have a child, have legalguardianship or adopt a child), you may add the new dependent(s) to your coverage. Contact the Fundour coverage. Contact the Offi ce for information on enrolling new dependents.

You are also responsible for notifying the Fund Offi ce if a dependent ceases to be eligible for coverage ases to be eligiblunder the Plan—if you divorce or legally separate from your spouse, remarry, or a child reaches aremarry, or a chlimiting age, gets married, or stops going to school full-time.

Failure to provide this information in a timely manner will result in the member being responsible to b b ireimburse the Fund for payments made on behalf of ineligible dependents. If the participant does notmake proper restitution to the Fund, future benefi ts will not be paid.

Do I have to undergo a physical exam before I can be coveered?

No, you do not need to have a physical exam before being covered.

Offi ce can reduce any exclusion for pre-existing conditions under that group health plan or health insurance policy. Th e certifi cate will indicate the period of time you were eligible under our Plan and certain additional information as required by law.

Th e certifi cate will be sent to you and/or your eligible dependents by fi rst-class mail shortly after your coverage under this Plan ends. If you elect COBRA continuation coverage, another certifi cate will be sent by fi rst-class mail shortly after the COBRA continuation coverage ends.

You or a dependent may also request a copy of the certifi cate at any time within 24 months after your

coverage terminates.

Conversion of Life Insurance

Participant life insurance may be converted to individual policies at the participant’s expense when coverage ends. See page 34 for more information.


Medical Plan

Th is section describes Plan provisions for hospitaliza-tion, major medical, doctor treatment, complementary care and how the preferred provider network works.

FAST FACTS:

Using a provider who participates in the PPO Network will keep your expenses to a minimum.

Certain services require pre-authorization.

Your participation in Plan A or Plan B is determined by the number of hours you work in a 12-month Qualifying Period.

Your medical benefi ts provide coverage for diagnosis and treatment of non-occupational illnesses and

•

••

injuries, as well as certain preventive care. Included are visits to the doctor, hospitalization, surgery, and treatment for mental illness or substance abuse, among other things.

Th e accompanying chart is intended to provide a convenient quick-reference guide to selected medical benefi ts. Th e percentages shown as payable by the Fund apply to covered charges only—the negotiated rate (for PPO providers) or the reasonable and customary charges (for non-PPO providers).

Unless noted otherwise, all benefi t payments discussed below are after the deductible. More detailed information, including conditions for payment of diff erent benefi ts, follows the chart.

QUICK REFERENCE GUIDE FOR SELECTED MEDICAL EXPENSES

Provision

How It Works

Plan A Plan B

PPO ProviderNon-PPO Provider

in PPO Area PPO ProviderNon-PPO Provider

in a PPO Area

Maximum Lifetime Benefi t $1 million per individual $1 million per individual

Annual Deductible per Calendar Year

$250 per individual;$500 per family

$750 per individual;$1,500 per family

$500 per individual;$1,000 per family

$1,000 per individual;$2,000 per family

Hospital and Emergency Care

Hospital-Inpatient & Ambulatory Surgical Facility (per admission)

Fund pays 100% of the fi rst $50,000 plus 85% of the excess charges with an out-of-pocket maximum of $2,000




Hospital-Outpatient Fund pays 100% after $15 copayment

Fund pays 80% of R&C fees for most procedures

Fund pays 90% after $15 copayment

Fund pays 75% of R&C fees for most procedures

Emergency Treatment Fund pays 100% after $75 additional copayment for each emergency medical treatment (waived if admitted to the hospital), and after the initial $15 copayment

Fund pays 80% of R&C fees, after $75 copayment for each emergency medical treatment (waived if admitted to the hospital)

Fund pays 100% after $75 additional copayment for each emergency medical treatment (waived if admitted to the hospital), after the initial $15 copayment

Fund pays 75% of R&C fees, after $75 copayment for each emergency medical treatment (waived if admitted to the hospital)

General Medical Care

Annual Physical Exam (must be at least one year old)

Fund pays 100% in network after $15 copayment (no deductible)

Fund pays 100% in network after $15 copayment (no deductible)


Provision

How It Works

Plan A Plan B



in a PPO Area

Hearing Services:

Device• Fund pays $800 for a hearing device per ear, once every fi ve years

Fund pays $800 for a hearing device per ear, once every fi ve years

Exam• Paid same as physician offi ce visit Paid same as physician offi ce visit

Physician Offi ce Visit and Surgeon’s Expenses


In most cases, Fund pays 80% of R&C fees


In most cases, Fund pays 75% of R&C fees

Maternity and Well Baby Care

Maternity Care Paid same as other Plan A medical treatment Paid same as other Plan B medical treatment

Well Baby Care Paid same as other Plan A medical treatment Paid same as other Plan B medical treatment

Certifi ed Midwifery and Birthing Centers

Fund will pay 100% of the charges for services of a certifi ed nurse midwife or birthing center provided the services or supplies would have been covered had treatment been rendered by any other duly licensed practitioner or at a hospital

Special Infant Formula The Fund will pay 70% of the charges, up to a maximum benefi t of $1,000 per quarter for infants up to 12 months

Additional Medical Care

Mental Health Care: Must be pre-authorized by the Member Assistance Program (The Wellness Corporation)

Inpatient(maximum 25 days per calendar year)

• Paid same as other Plan A inpatient care Paid same as other Plan B inpatient care

Outpatient (maximum 24 visits per calendar year)

• For visits after fi rst eight visits under the MAP, Fund pays 100% after $15 copayment per visit

For visits after fi rst eight visits under the MAP, Fund pays 100% after $15 copayment per visit

Treatment of Alcoholism or Substance Abuse:Must be pre-authorized by the Member Assistance Program (The Wellness Corporation)

Inpatient (25 days max per lifetime)

• Paid same as other Plan A inpatient care Paid same as other Plan B inpatient care

Outpatient($1,500 max per calendar year)

• For visits after fi rst eight visits under the MAP, Fund pays 100% of fi rst $500 in covered charges and 80% of remaining covered charges

For visits after fi rst eight visits under the MAP, Fund pays 100% of fi rst $500 in covered charges and 80% of remaining covered charges

Complementary Care(see page 16 for complete list, pre-authori-zation requirementsand visit limitations)

Fund will pay 80% of the provider’s charge, up to a maximum benefi t of $50 per visit

Fund will pay 80% of the provider’s charge, up to a maximum benefi t of $50 per visit

Outpatient physical, occupational and speech therapy


Fund pays 80% of reasonable and customary fees


Fund pays 75% of reasonable and customary fees

Hospice Care The Fund will pay 100% of the charges certifi ed by BlueCross BlueShield for covered services and supplies for up to a six-month period

Home Health Care The Fund will pay 100% of the charges certifi ed by BlueCross BlueShield for visits made by a home health care agency for care at home for up to 90 visits per calendar year

Durable Medical Equipment (pre-authorization required by BlueCross Blue-Shield and limits apply)

Plan provides benefi ts for the purchase or rental of certain durable medical equipment for up to $5,000, renewable annually


All claims must be submitted to the Fund Offi ce no later than 90 days from the date of service. Do not pay the physician or hospital, other than your copayment, before you receive an Explanation of

Benefi ts (EOB) from the Fund Offi ce.

The Plan DeductibleTh e Plan deductible is the amount that you must pay each calendar year toward your covered medical expenses before the Plan will begin to pay medical benefi ts. All medical expenses, whether in network or out of network, are subject to the Plan deductible. (Th ere is one exception: annual physical exams are not subject to the deductible.) Th e annual Plan deductibles are:

If you move from Plan A to Plan B, or vice versa, during a calendar year, your payments toward your deductible will accumulate. For example:

If you have met the individual $250 calendar-year PPO Provider deductible for Plan A and then switch to Plan B for the next six-month Eligibility Period, you must pay an additional $250 to meet the individual $500 calendar-year PPO Provider deductible for Plan B.

If you have met the $500 individual calendar-year PPO Provider deductible for Plan B and then switch to Plan A for the next six-month Eligibility Period, you automatically meet the $250 individual calendar-year PPO Provider deductible for Plan A.

Lifetime Maximum for Benefi t PaymentsTh e Fund will not pay more then $1 million for all covered expenses incurred by an individual in his lifetime. Th is lifetime maximum applies to both Plan A and Plan B.

Preferred Provider Organization (PPO) ProvidersTh e Fund has entered into an arrangement with a Preferred Provider Organization (PPO) that contracts with hospitals, physicians and other health

•

•

Plan A Annual Deductible Plan B Annual Deductible

PPO Provider

Non-PPO Provider in PPO Area

PPO Provider

Non-PPO Provider in PPO Area

$250 per individual

$750 per individual

$500 per individual

$1,000 per individual

$500 per family

$1,500 per family

$1,000 per family

$2,000 per family

care providers to provide you and your dependents with medical services at discounted rates.

Th e Fund’s PPO is BlueCross BlueShield of Massachusetts for most medical expenses. Th e Wellness Corporation and the Member Assistance Program (MAP) cover mental health and substance abuse issues and complementary care.

To receive the highest benefi t level (in-network benefi ts) under the Plan, you need to choose providers who participate in the BlueCross BlueShield PPO Provider network. BlueCross BlueShield off ers many types of plans with diff erent networks of providers. Th ere are some BlueCross BlueShield providers who do not participate in the PPO network of providers, services will be considered out-of-network, and will be paid at out-of-network benefi t levels.

Since there are always changes occurring with the professional services network, it is strongly suggested that you ask a provider if they are participating members of your specifi c state BlueCross BlueShield Preferred Provider Organization, or access the BlueCross BlueShield Web site (www.BCBS.com) to obtain a provider’s current network status prior to receiving care. In addition, at any time you can fi nd out if any provider is a member of the network by contacting the Fund Offi ce or by calling the telephone number on your ID card. Updated provider lists are available from the Fund Offi ce free of charge.

If your physician is not in the PPO network, you may request that BlueCross BlueShield contact him or her about joining it.

If your physician does not have privileges at a PPO hospital, ask him or her to consider getting privileges.

In an Emergency

If you need to use a non-PPO provider in an emergency, the Fund will pay benefi ts at the level that would have been payable if you had used a PPO provider. Covered charges will be limited to reasonable and customary charges.

Required Pre-AuthorizationsTh e Fund requires pre-authorization for certain services, as summarized in the accompanying chart on page 14.

If you fail to comply with the requirements, the penalty could range from a $250 reduction (for an inpatient admission) in the amount paid by the Fund to a complete denial of the claim (for all other services requiring pre-authorizations).


Situation Pre-Authorization Requirement

Non-emergency admission to a hospital

You or your doctor must contact BlueCross BlueShield for pre-authorization at least 10 days before admission.

Admission to a skilled nursing facility

You or your doctor must contact BlueCross BlueShield for pre-authorization at least 10 days before you are admitted.

Emergency admission to a hospital

You or someone acting on your behalf must contact BlueCross BlueShield within 48 hours of admission so that it can approve the hospital stay as soon as possible after admission.

Admission to a hospital for childbirth

You and your obstetrician or certifi ed mid-wife should call BlueCross BlueShield to pre-certify the hospital stay well in advance and should call again within 48 hours following admission.

If the date of admission is rescheduled or cancelled, you also must call BlueCross BlueShield to advise it of the new admission date.

You do NOT need pre-authorization for a hospital stay for a mother and newborn child if the hospital stay does not exceed 48 hours following a vaginal delivery or 96 hours following a cesarean section.

Complementary care You or your provider must call The Wellness Corporation to get pre-authorization before you visit the provider.

Hospice care You or your doctor must call BlueCross BlueShield to get pre-authorization before you make any arrangements for hospice care.

Home health care You or your doctor must call BlueCross BlueShield to get pre-authorization before you make any arrangements for home health care.

Mental health treatment You must call the Member Assistance Program to get pre-authorization before admission to a facility or visits to a provider.

Treatment for alcoholism or substance abuse

You must call the Member Assistance Program to get pre-authorization before admission to a facility or visits to a provider.

Durable medical equipment You or your doctor must call BlueCross BlueShield to get pre-authorization before you purchase or rent any durable medical equipment.

Gastric bypass surgery Your doctor must call BlueCross BlueShield to get pre-authorization before you make any arrangements for gastric bypass surgery.

PLAN REQUIREMENTS FOR PRE-AUTHORIZATION

Th e Wellness Corporation (mental and nervous and substance abuse) or BlueCross BlueShield (inpatient hospital stay) will also conduct concurrent review of your hospital stay once you are admitted and help

you plan your discharge.

Response Time

Requests for pre-authorization are usually considered “pre-service claims.” Decisions are generally made within 15 days (or 30 days if Th e Wellness Corporation, BlueCross BlueShield or the Member Assistance Program (MAP) needs more time, or later still if it needs more information from you or your doctor). Decision-making will be expedited if your case warrants treatment as an “urgent care claim,” meaning that following the time frames just described for pre-service claim decisions:

could seriously jeopardize your life or health or your ability to regain maximum function; or

in the opinion of a physician with knowledge of your condition, would subject you to severe pain that could not be adequately managed without the care or treatment that is the subject of the request for pre-authorization.

A decision on a case meriting treatment as an urgent care claim will be made within 72 hours. You or your physician should alert Th e Wellness Corporation, BlueCross BlueShield or MAP if your pre-authorization request needs to be handled as an urgent care claim. (“Urgent care claims” are not to be confused with emergency treatment or treatment at an urgent care facility, which do not require pre-authorization.)

•

•


Intent of Required Pre-Authorizations

Th e pre-authorizations required under the Plan

work to control your costs, for example, by

preventing unnecessary hospitalization and hospital

stays that extend beyond the time it is medically safe

to discharge a patient.

You should note the following, however:

Neither the Fund nor Th e Wellness Corporation, BlueCross BlueShield or MAP is responsible for either the quality of health care services actually provided or for the results if a member chooses not to receive health care services that are denied pre-authorization;

All treatment decisions rest with you and your physician. You should follow whatever course of treatment you and your physician believe to be the most appropriate, although benefi ts payable by the Fund may be aff ected by the pre-authoriza-tion program; and

Th e pre-authorization program is not intended to diagnose or treat medical conditions, validate eligibility for coverage, or guarantee payment of Plan benefi ts. Pre-authorization does not necessarily mean benefi ts will be paid. For example, benefi ts would not be payable if your eligibility for coverage ended before the services were rendered, if the services were not covered by the Plan, or the maximum benefi t had already been paid.

If the services for which you are requesting pre-

authorization are not approved, you may still

proceed with obtaining them. Be aware, however,

that the Fund may pay reduced benefi ts for them or

no benefi ts at all.

You may also appeal an adverse decision. See

“Claims and Appeals Procedures” on page 57.

EmergenciesIn a medical emergency, you should seek the

necessary treatment immediately.

Benefi ts for emergency medical treatment are paid

the same as benefi ts for other medical treatment.

Remember, however, that you or someone acting on

your behalf must call BlueCross BlueShield to report

•

•

•

an emergency hospitalization within 48 hours of

admission if you want to avoid the possibility that

your benefi t payment will be reduced.

What the Plan CoversCovered services and supplies include those

described in the following pages. Exclusions and

limits that apply to specifi c services and supplies are

described with those services and supplies; others

are described in the “General Limits and Exclusions”

on page 45.

Except as noted in the “General Limits and

Exclusions,” the Plan will not pay benefi ts for any

expenses related to an occupational injury or illness.

Th e billed charges that will be considered covered

expenses will never be more than the negotiated rate

(if you use a PPO provider) or the reasonable and

customary charges.

You will be responsible for your share of covered

expenses and any amounts that exceed covered

expenses. Non-PPO providers are under no

obligation to limit their charges to amounts

considered covered expenses under the Plan.

If you move from Plan A to Plan B, or vice versa,

your claim will be paid based on the Plan you were

covered under on the date services were received.

However, if you are hospitalized, your claim will be

paid based on the Plan you were covered under on

the date you were admitted to the hospital.

All benefi t payments are subject to the Plan’s

maximum lifetime benefi t.

Hospital and Ambulatory Surgical Facility Charges

Th e Plan provides benefi ts for a hospital stay, outpatient services, or ambulatory surgical services. To receive the maximum benefi ts for these services, be sure to contact BlueCross BlueShield for necessary pre-authorizations (see page 14 for a list). Th e services eligible for reimbursement under the Plan include:

Covered

Charges resulting from your inpatient stay in a •


hospital. Th is includes charges for a semi-private room or an intensive care or similar unit. If you have a private room, even if your physician has ordered it, only charges equivalent to the hospital’s average semi-private room-and-board charge are covered. You are responsible for the rest of the bill.

Charges resulting from your confi nement as an inpatient in an extended care facility, provided you are admitted within 24 hours after your discharge from a hospital confi nement.

Outpatient charges for a surgical operation.

Physician copayments are covered for in-hospital physician visits.

Outpatient charges for emergency treatment within 48 hours following an accidental bodily injury.

Pre-admission testing—diagnostic tests and x-rays ordered by a physician if the charges are eligible expenses and the tests and x-rays are conducted in the outpatient department of a hospital within seven days of an actual admission to a hospital for treatment of the condition which made the tests necessary. If the admission does not take place, the testing may still be covered if the admission is postponed or cancelled for one or more of the following reasons:

the tests show a condition requiring medical treatment, prior to admission;

a medical condition develops that delays the admission;

a hospital bed is not available on the scheduled date of admission; or

the tests indicate that, contrary to the attending physician’s expectations, the admission is not necessary.

Expenses incurred for the use of an ambulatory surgical facility are covered as an in-hospital service. Th e benefi t payable will not exceed the hospital expense benefi t.

For successive hospital confi nements to be considered separate admissions, they must be due to entirely unrelated causes or separated by an interval of six months or more, or you must have returned to active work for at least one full working day, for members only. Charges made by a hospital will be deemed to include charges made by an anesthetist for the administration of anesthesia, charges by a professional ambulance service to and from the hospital and charges by a radiologist or pathologist.

•

••

•

•

–

–

–

–

•

Surgical Expenses

Covered

All generally accepted surgical procedures,

including sterilization procedures (vasectomies and

tubal ligations) are covered by the Plan. Th e Plan

also covers gastric bypass surgery. To receive the

maximum benefi ts for surgical services, be sure to

contact BlueCross BlueShield for necessary pre-

authorizations. (See the “Non-emergency admission

to a hospital” section of the pre-authorization chart

on page 14 for details.)

Special Provisions Regarding Women’s Care

Th e Plan complies with Federal laws that guarantee

certain rights to women:

Under the Women’s Health and Cancer Rights Act of 1998, all plans that cover mastectomies are also required to cover related reconstructive surgery. Available reconstructive surgery must include both reconstruction of the breast on which surgery was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. Coverage must also be available for breast prostheses and for the physical complications of mastectomy, including lymphedemas. Th ese services are elective and are chosen by the patient in consultation with the attending physician. Th ey are subject to a plan’s usual deductible and copayment provisions.

Not Covered

Cosmetic surgery, except as required because of accidental injury or reconstructive surgery following a mastectomy.

Complementary Care

Th e Wellness Corporation provides benefi ts for certain, non-traditional services and treatments. To receive the benefi ts for these services, be sure to contact Th e Wellness Corporation for necessary pre-authorizations. In addition, Th e Wellness Corporation can refer you to quality complementary care providers when you call for your required pre-authorization.

•

•


Complementary care that requires pre-authorization from Th e Wellness Corporation:

Limitation: Th ere is a combined limit of 40 visits per calendar year for all of these services:

Biofeedback

Homeopathy

Massage therapy (these visits can make up no more than 12 of the 40 under the combined limit)

Naturopathy

Nutrition

Oriental medicine

Complementary care that does not require pre-authorization:

Limitation: 30 visits per calendar year

Acupuncture (from a state-certifi ed acupuncturist)

Complementary care that requires utilization of the BlueCross BlueShield PPO network:

Limitation: 30 visits per year

Chiropractic

Physician Offi ce Visit

Th e Plan covers routine offi ce visits and any x-rays

and/or lab services.

Annual Physical Exam

Th e Plan covers routine, annual physicals for participants who are at least one year old. If your physician does not do all the testing in his or her offi ce, make sure you submit itemized bills for tests

or x-rays with your claim.

Covered

Services rendered in the ordinary course of a physical examination and not for diagnosis or treatment of an illness or injury

Measurements of height, weight, hearing, blood pressure and pulse

Urinalysis

•••

•••

•

•

•

•

•

Blood chemistry (including blood sugar and blood cholesterol), PSA

Electrocardiogram

Mammograms

Chest x-rays

Lung capacity

Pelvic examinations

Pap tests for females

Colonoscopy

Maternity Care

Special Provisions Regarding Women’s Care

Th e Plan complies with Federal laws that guarantee certain rights to women:

Under the Newborns’ and Mothers’ Health Protection Act of 1996, group health plans and health insurance issuers off ering group health insurance coverage generally may not restrict benefi ts for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (for example, the doctor), after consultation with the mother, discharges the mother or newborn earlier.

Also, under Federal law, plans and issuers may not set the level of benefi ts or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.

In addition, a plan or issuer may not, under Federal law, require that a doctor or other health care provider obtain authorization for prescribing a length of stay after childbirth of up to 48 hours (or 96 hours).

Covered

Normal deliveries (see “Required Pre-Authorizations” on page 14 for information on approvals necessary if you wish to receive unreduced benefi ts):

Semi-private room and board;

Special services and nursery charges;

•

•••••••

•

––


Physician’s services, including prenatal and post-natal care; and

Hospital charges for anesthesia (also covered when administered by a physician, other than the attending physician, who is not an employee of the hospital)

Complications of pregnancy:

Treatment for any complications of pregnancy, including cesarean delivery;

Semi-private room and board (including nursery charges); and

Physician’s services.

Care of the newborn:

Nursery charges;

Th e initial examination of the well newborn by a physician, other than the mother’s attending physician, and daily medical care during the routine stay of the mother; and

Circumcision of the newborn.

Benefi ts will be payable as they would for treatment of any other medical condition.

Certifi ed Midwifery and Birthing Centers Benefi tBenefi ts are also available for the services of a midwife and birthing center as an alternative to the benefi ts described above.

After meeting the deductible, the Fund will pay 100% of the charges for services of a certifi ed nurse midwife (no deductible), provided the expenses for such services would be reimbursed if they were performed by any other duly licensed practitioner. Th e Fund will also pay 100% of the charges when a birthing center is used in lieu of a hospital and the services or supplies would have been covered had treatment been rendered at a hospital.

“Certifi ed nurse midwife” means a nurse midwife authorized to practice midwifery in the state in which such services are performed. Th e services provided must be within the lawful scope of practice for a certifi ed nurse midwife.

“Birthing center” means a duly licensed facility that is equipped and operated solely to provide prenatal care, to perform uncomplicated spontaneous deliveries, and to provide immediate postpartum care. A birthing center must have all of the following:

–

–

•–

–

–•

––

–

Staffi ng that includes direction by at least one physician specializing in obstetrics or gynecology, the presence of a physician or certifi ed nurse midwife during each birth and immediate postpartum period, provision of full-time, skilled nursing services in the delivery rooms and recovery rooms (under the direction of a registered nurse or certifi ed nurse midwife), and extension of staff privileges to physicians who provide obstetrical and gynecological care in an area hospital.

A facility and equipment that includes at least two beds or birthing rooms for patients during labor and delivery, diagnostic x-ray and laboratory equipment (or a contract to use such equipment at an area medical facility), and equipment and supplies for administration of local anesthetic, for performing minor surgery, and for handling medical emergencies (including oxygen and resuscitation equipment, intravenous fl uids and drugs to control the mother’s bleeding, and drugs to assist the newborn in breathing).

Policies and procedures by which the facility regularly charges patients for services and supplies, admits only patients with low risk pregnancies, contracts with an area hospital and displays written procedures for immediate transfer of mother and child in emergency cases, and has an on going quality assurance program with reviews by physicians, other than those who own or direct the facility.

Not Covered

Genetic testing (except for amniocentesis, chorionic villus sampling, and alphafetoprotein analysis in pregnant women when found medically necessary by BlueCross BlueShield)

Special Infant Formula (up to 12 months of age)

Covered

Non-prescription enteral infant formula for home use for which a physician has issued a written order and which is medically necessary for the treatment of one of the following conditions:

Malabsorption caused by Crohn’s disease

Ulcerative colitis

•

•

•

•

•

––


Gastroesophageal refl ux

Gastrointestinal motility

Chronic intestinal pseudo-obstruction

Th e Fund will pay 70% of the charges, up to a maximum benefi t of $1,000 per quarter and up to twelve months of age, provided a physician initially issues a written order identifying one of the fi ve medical conditions previously listed and issues follow-up written orders for the infant formula every quarter.

Well Baby and Child Care

Covered

Physical exams

History

Measurements

Sensory screenings

Development screening

Hereditary and metabolic screening

Immunizations

Tuberculin tests

Blood and urine tests

Benefi ts are payable in accordance with the Plan’s Scheduled Benefi ts.

Treatment of Mental and Nervous Disorders

Th e Plan covers treatment of mental and nervous disorders that are pre-authorized by the Member Assistance Program (MAP). You must also use a MAP-approved facility or provider to receive the benefi ts below:

Covered

Inpatient treatment: up to 25 days per calendar year.

Partial Hospitalization Programs (PHP) or Intensive Outpatient Programs (IOP): up to 10 days per calendar year. PHP/IOP are programs that provide treatment in the outpatient setting of not less than three hours and not more than eight hours per day. If the cost of one session of partial hospitalization exceeds 50% of the cost of one day of inpatient care at the same hospital, such care will be considered inpatient care, subject to the same provisions and limits as care for any other illness.

–––

•••••••••

••

Adolescent Acute Residential Treatment (AART): up to 10 days per calendar year. For this benefi t, adolescents are covered dependents from 13 up to 19 years of age.

Adolescent Acute Residential Treatment means 24 hour psychiatric treatment in an unlocked setting for adolescents who require short-term clinically intensive psychiatric care. Treatment includes assessment, consultation, psychophar-macology, family therapy, treatment specializa-tion, educational services and recommendations. Treatment teams collaborate with each patient, the patient’s family, school, outpatient treatment programs and community agencies to promote a

smooth transition back to the community.

Outpatient treatment: up to 24 visits per calendar year, after you have used the eight visits per year available under the Member Assistance Program(see page 27).

Treatment of Alcoholism and Substance Abuse

Th e Plan covers treatment of alcoholism and substance abuse that is pre-authorized by the Member Assistance Program (MAP). You must use a MAP-approved facility to receive the benefi ts listed below:

Inpatient admission for the treatment of substance abuse: up to 25 days per lifetime for detoxifi cation and short-term rehabilitation. An initial inpatient admission for a maximum of 5 to 10 days must be pre-authorized by the MAP. A subsequent inpatient admission may be authorized only if you followed the aftercare plans recommended by the treating providers and the MAP. If aftercare plans are not followed, a subsequent short-term (maximum 3 days) inpatient admission may be authorized for detoxifi cation only if it is determined to be necessary and appropriate by the MAP Case Manager. Initial and subsequent inpatient admissions will be subject to the days-per-lifetime limit specifi ed above for detoxifi cation and rehabilitation.

Partial hospitalization: up to 10 days per calendar year. “Partial hospitalization” means continuous treatment of not less than three hours and not more than 12 hours per day. If the cost of one

•

•

•

•


session of partial hospitalization exceeds 50% of the cost of one day of inpatient care at the same hospital, such care will be considered inpatient care, subject to the same provisions and limits as care for any other illness.

Outpatient treatment is available only after you have used the eight visits per calendar year available under the MAP (see page 27).

Benefi ts for inpatient care will be paid the same as for any other illness, subject to the days-per-lifetime limit above for detoxifi cation and rehabilitation.

Hospice Care

Hospice care benefi ts are available in the case of a patient who has a life expectancy of six months or less. Th e hospice coordinates inpatient and home care for the patient and the family as a unit. Th e hospice provides care to meet the special needs of the patient and the family during the fi nal stages of terminal illness and during bereavement.

Covered

Outpatient hospice care for services rendered on an outpatient basis in the home setting, as follows:

Part-time (intermittent) nursing care given in the home by a registered nurse (R.N.), licensed practical nurse (L.P.N.), or licensed public health nurse

Hospice care or treatment visits by hospice staff personnel who are full-time employees of the hospice

Physical and respiratory therapy

Oxygen and equipment for the individual’s care

Th e rental of wheelchairs and hospital-type beds and other medical equipment for the patient’s care

Homemaker services

Charges incurred for professional counseling sessions with the patient’s family members during the period of hospice care

Bereavement services for professional counseling sessions with the patient’s family members for help in coping with the death of the patient within the three-month period following the patient’s death

•

•

•

–

–

–

–

–

–•

•

Care must be provided by a team of medical personnel, counselors, and other individuals who have had special training. It can include homemakers who work in conjunction with the hospice. Th e team must act with the purpose of helping the patient and the family cope with physical, social, psychological, and spiritual needs.

“Hospice” means a facility that operates as a unit of a program that admits only patients who do not have a reasonable prospect for a cure and who have a life expectancy of six months or less, as certifi ed in writing by the attending physician. A hospice is separate from any other facility. However, it may be affi liated with a hospital, nursing home, or home health care agency. It must be approved as meeting the legal requirements, if any, of the state locality or authority having jurisdiction over licensing and approval.

Not Covered

Hospice care or treatment that is not recommended or approved by a physician

Hospice care or treatment for which there would have been no charge had there been no coverage

Hospice care or treatment for any condition that is not payable under other provisions and benefi ts of this Fund

Hospice care or treatment for any services rendered by a person who is a member of the patient’s family or who ordinarily resides in the patient’s home

Hospice care or treatment for services for which benefi ts are not payable according to the “General Limits and Exclusions” on page 45

Home Health Care

Home health care benefi ts are available for necessary services or supplies furnished in an individual’s home in accordance with a home health

•

•

•

•

•

NETWORK PROVIDERS FOR HOME HEALTHCARE OR DURABLE MEDICAL EQUIPMENTThe PPO network for home health care or durable medical equipment is through BlueCross BlueShield. They can refer you to a network provider when you Call for the required pre-authorization.


care plan. To be eligible for coverage, the home health care must start within seven days after release from a hospital confi nement for the same or related condition. Each visit by a member of a home health care team will be considered one home health care visit. To receive the maximum benefi ts, be sure to contact BlueCross BlueShield for necessary pre-authorizations.

Covered

Part-time or intermittent nursing care by a registered nurse (R.N.) or by a licensed practical nurse (L.P.N.) under the supervision of an R.N., if the services of an R.N. are not available

Part-time or intermittent home health aide services, consisting primarily of patient care of a medical or therapeutic nature, by other than an R.N. or L.P.N.

Physical therapy, occupational therapy and speech therapy

Medical supplies, drugs, and medications prescribed by a physician and laboratory services by or on behalf of the home health care agency, to the extent such items would have been covered under this Fund if the patient had remained in the hospital

“Home health care plan” means a program:

for continued care and treatment of the patient;

certifi ed and approved by BlueCross BlueShield;

established and approved in writing by such patient’s attending physician within seven days following termination of a hospital confi nement as a resident inpatient;

for treatment of the same or related condition for which the patient was hospitalized; and

including certifi cation in writing by a physician that the proper treatment of the illness or injury would require continued confi nement as a resident inpatient in a hospital in the absence of the services and supplies provided as part of the home health care plan.

“Home health care agency” means an agency or organization that meets fully every one of the following requirements:

it is primarily engaged in and duly licensed by the appropriate licensing authority to provide skilled nursing services and other therapeutic services (if such licensing is required);

•

•

•

•

•••

•

•

•

it has policies established by a professional group associated with the agency or organization (this professional group must include at least one physician and at least one registered nurse (R.N.) to govern the services provided, and it must provide for full-time supervision of such services by a physician or by an R.N.;

it maintains a complete medical record on each patient; and

it has a full-time administrator.

Durable Medical Equipment

Outpatient benefi ts are provided based on the allowed

charge for durable medical equipment bought or

rented by the member from an Appliance Company

(or another provider who is designated by BlueCross

BlueShield to furnish the specifi c covered appliance)

for use in the home. Th ese benefi ts are limited to

equipment that: can stand repeated use; serves a

medical purpose; is medically necessary for the

member; is not useful if the member is not ill or

injured; and can be used in the home.

Some examples of covered durable medical equipment include (but are not limited to):

Hospital beds, wheelchairs, crutches, and walkers

Glucometers which are medically necessary due to the patient’s type of diabetic condition

Bath seats

Raised toilet seats

Bed pans

Motorized scooters, up to $2,500

Oxygen

Th ese benefi ts are limited to a dollar benefi t maximum for each member in each calendar year. Refer to the Schedule of Eligible Medical Expenses for the amount of the benefi t limit that applies for these covered services.

From time to time, the equipment that is covered by this Plan may change. Th is change will be based on BlueCross BlueShield’s periodic review of medical policy and medical technology assessment guidelines to refl ect new applications and technologies.

BlueCross BlueShield will decide whether to authorize the renting or buying of the durable

•

•

•

••

•••••


medical equipment. If BlueCross BlueShield decides that the equipment should be rented, benefi ts will not be more than the amount that would have been paid if the equipment were bought.

Th ese benefi ts are provided for the least expensive equipment of its type that meets the member’s needs. If BlueCross BlueShield determines that the member chose durable medical equipment that costs more than what the member needs for his or her medical condition, benefi ts are provided only for those charges that would have been paid for the least expensive equipment that meets the member’s needs.

Hearing Care

Th e Plan provides coverage for hearing exam and device as follows:

Covered

Provider services for examination and testing by a licensed physician or audiologist

Hearing device prescribed by a physician or audiologist—one device per ear every fi ve years to the day from original purchase

Other Medical Charges

Covered

Expenses incurred from an attempt at suicide or a self-infl icted injury, including complications thereof.

Th e services of a licensed physician, whether inpatient or outpatient.

Th e services of a registered graduate nurse (R.N.) other than a nurse who ordinarily resides in your home or who is a member of your or your spouse’s family.

Emergency admission services: a complete history and physical exam of a patient who is admitted by a physician as an inpatient in an emergency, when treatment is immediately assumed by another physician.

Intensive care services: services by a physician, other than the attending physician, to treat an unusual aspect or complication of an illness or injury.

•

•

•

•

•

•

•

Services to interpret diagnostic x-rays and other imaging services and diagnostic laboratory services.

Anesthesia and anesthesia services rendered by a physician, other than the operating surgeon or his/her assistant, who is not an employee of the hospital.

Diagnostic admission services: when hospital-ization for diagnostic purposes is necessary, the same hospital and physician benefi ts as described previously will be provided.

Coverage in an outpatient department or emergency room or health center: charges for the following services provided in a hospital outpatient department or emergency room or in a community health center when necessary to diagnose or treat an illness or injury:

Surgery

Diagnostic x-rays and other imaging services

Diagnostic laboratory services

Hemodialysis treatment, equipment and supplies

Radiation therapy

Extension of Medical Benefi ts in Case of Disability

Th e Fund will continue to pay benefi ts for medical expenses for a specifi c illness or injury incurred on any day during the calendar year in which the covered individual who is disabled ceases to be covered under the Plan and during the next succeeding calendar year, provided that:

the medical expenses incurred are in connection with an injury or illness for which the covered individual is totally disabled at the time he ceases to be covered;

the covered individual is continuously so disabled to the date each medical expense is incurred; and

you are not entitled to benefi ts for such medical expenses under any other group policy, whether issued by an insurance company or by any other insurer for benefi ts of a type similar to those provided here.

•

•

•

•

–

–

–

–

–

•

•

•


Filing a Claim for Medical Plan Benefi ts

Note: Th e discussion below applies to “post-service claims”—claims you submit after you have received a service. Requests for required pre-authorization are also considered claims. See “Required Pre-Authorizations” earlier in this chapter and “Claims and Appeals Procedures” on page 57 for more information on those types of claims.

PPO Providers

Any provider in the PPO network will be paid directly by BlueCross BlueShield. If you use a PPO provider, you are responsible for your deductible and copayment amounts.

Non-PPO Providers

To fi le a claim for benefi ts when you use a non-PPO provider you must submit a completed claim form to the Fund Offi ce, unless your hospital, doctor, or other health care provider uses a standard billing form, such as a UB 92 or HCFA 1500, and fi les it directly with the Fund on your behalf.

If you have to fi le an inpatient and/or outpatient claim for substance/alcohol abuse, nervous/mental

illness, or complementary care you must have the

service pre-authorized by Th e Wellness Corporation

prior to submitting the claim to the Fund Offi ce.

You may obtain a health claim form from the Fund

Offi ce by calling 781-272-1000 or 800-342-3792, or

from our Web site at www. MLBF.org.

All of the following information must be completed

on the claim form that you get from your provider(s):

Your name and Social Security number

Your address

Your date of birth

Your marital status

Information on other insurance coverage (if any)

Th e patient’s name and address and relationship

to you

Th e patient’s date of birth

Th e patient’s sex

•

•

•

•

•

•

•

•

Th e patient’s student status

If the condition is related to patient’s employment

or an accident, information on the employment or

accident

Date(s) of service

Date the patient is able to return to work

Date of total/partial disability

Name of referring physician

Hospitalization dates, if applicable

CPT-4 (the code for physician services and

other health care services found in the Current

Procedural Terminology, Fourth Edition or later,

as maintained and distributed by the American

Medical Association)

ICD-9 (the diagnosis code found in the

International Classifi cation of Diseases,

9th Edition or later, Clinical Modifi cation

as maintained and distributed by the U.S.

Department of Health and Human Services)

Billed charge, amount paid, and balance due

Signature of service provider

Federal taxpayer identifi cation number (TIN) of

the provider

Provider’s billing name and address

Most accepted standard claim forms contain an

assignment of benefi ts agreement, in the event you

wish to assign your hospital or surgical benefi ts

directly to the hospital or doctor. Upon receipt of

the assignment agreement, the Fund Offi ce will

directly pay these benefi ts to your health care

provider.

When Claims Must Be Filed

Claims must be fi led within 90 days from the date

the charges were incurred. If you have any questions

about submitting your claim, contact the Fund Offi ce.

For information on what to do if you disagree with

the decision made in regard to your claim, see

“Claims and Appeals Procedures” on page 57.

•

•

•

•

•

•

•

•

•

•

•

•

•


Prescription Drug Benefi ts

Th e Plan off ers prescription drug coverage at retail pharmacies and through a mail-order program.Th is benefi t is off ered through Express Scripts.

FAST FACTS:You can walk into any participating retail pharmacy and have your prescription fi lled there. If you use a network pharmacy, you pay only your copayment at the time of purchase.

Only the initial fi ll and two refi lls of the same prescription (three 30-day supplies) will be covered at the applicable copayment in the accompanying chart. Your copayment for any additional refi lls will be 50% of the cost.

Prescriptions for drugs you take on a regular basis must be fi lled and refi lled through the mail-order program, at a cost savings to you.

Th e amount of your copayment will depend on whether your drug is a generic, a preferred brand-name, or a non-preferred brand-name. (“Preferred” means it is on the plan’s preferred medication list.)

Some drugs, for example, injectables, require pre-authorization.

Th e accompanying chart is intended to provide a convenient quick-reference guide to your prescrip-tion drug benefi ts. More detailed information follows the chart.

QUICK-REFERENCE GUIDE TO PRESCRIPTIONDRUG BENEFITS FOR PLANS A AND B

•

•

•

•

•

Use of Retail PharmaciesExpress Scripts has a network of participating

retail pharmacies. Although you may have your

prescription fi lled at either a participating or non-

participating pharmacy, there are two good reasons

for using a participating pharmacy:

You won’t have to worry about submitting a claim

for reimbursement—you pay any copayment

due at the time of purchase, and that’s it. Th e

pharmacy bills the Fund for the remaining cost.

You’ll save the Fund money and help it continue

providing benefi ts because of the discounted

prices negotiated with participating pharmacies.

If you use a participating retail pharmacy, simply

present your Express Scripts identifi cation card to

the pharmacy and pay the applicable copayment

from the accompanying chart.

If you use a non-participating pharmacy, you will

have to pay the full amount billed at the time of

purchase and submit a claim to Express Scripts.

Express Scripts will reimburse you for the allowable

amount, minus the applicable copayment.

Limit on Supplies from Retail Pharmacies

Only the initial fi ll and two refi lls of the same

prescription (three 30-day supplies) will be covered

at the applicable copayment in the accompanying

chart. Your copayment for any additional refi lls will

be 50% of the cost.

You are encouraged to use the mail-order program

when you need a 90-day or more supply of a

prescription drug.

•

•

Prescrip-tion fi lled at a retail pharmacy

You pay the following copayment per prescription for up to a 30-day supply:Generic drug: $5Preferred brand-name: $15Non-preferred brand-name: $25The Fund covers the remaining cost. Note: Your copayment for any refi lls at a retail pharmacy beyond the third fi ll will be 50% of the cost.

Prescrip-tion fi lled through the plan’s mail-order program

You pay the following copayment per prescription for up to a 90-day supply:Generic drug: $10Preferred brand-name: $30Non-preferred brand-name: $50The Fund covers the remaining cost.

PARTICIPATING PHARMACIES

To fi nd a participating pharmacy, call Express Scripts at 800-467-2006 or visit the Web site atwww.express-scripts.com.


Using the Mail-Order ProgramIf you use the mail-order program, you can get up to

a 90-day supply for the same amount you would pay

for two 30-day supplies at a retail pharmacy.

Th e mail-order program is a convenient way to

obtain maintenance or long-term medication. You

can obtain an Express Scripts envelope from the

Fund Offi ce or by calling Express Scripts. Fill in the

requested information on the envelope, making

sure you complete the allergy section if this is the

fi rst time you’ve ordered medication from Express

Scripts. You need to enclose your physician’s

prescription and your copayment or credit card

information.

You should receive your order within seven business

days. You will receive another mailing envelope

with your shipment. Please remember that reorders

should be sent approximately two weeks prior to

your medication running out. You may also order

refi lls by phone at 800-233-7139 or online at www.

express-scripts.com.

What the Plan CoversYour prescription drug benefi ts cover all

medications that by Federal law or state law require

a prescription and are prescribed by a licensed

practitioner (including new drugs approved by

Express Scripts).

Included in your program is insulin by prescription

and syringes and needles for injection of prescribed

covered drugs, when ordered by a physician.

The Preferred Medication ListTh e Preferred Medication List is Express Scripts’ list

of preferred brand-name drugs.

Th is list includes drugs that are therapeutically

equivalent to other drugs that are commonly

prescribed by doctors for specifi ed medical

conditions. Th e doctors and pharmacists on

the Express Scripts Pharmacy and Th erapeutic

Committee select the drugs on the list based on

their appropriateness, clinical effi cacy, and cost-

eff ectiveness in the delivery of pharmaceutical care.

If you have questions about whether a drug is on

the Preferred Medication List, you can call Express

Scripts at 800-467-2006 or visit www.express-

scripts.com.

Required Pre-AuthorizationsDispensing of certain drugs must be pre-authorized

by Express Scripts.

To request pre-authorization, your doctor should

call Express Scripts at 800-417-8164 or fax a letter of

medical necessity to 800-357-9577. (Th ese numbers

are for physicians only.)

If you have questions about which drugs require

pre-authorization, contact Express Scripts.

Requests for required pre-authorization are

considered “pre-service claims.” If you disagree

with the decision made on your doctor’s request

for pre-authorization, you may appeal it. See the

information on pre-service claims in “Claims and

Appeals Procedures,” starting on page 57.

Step Therapy ProgramIf you take prescription drugs regularly for certain

conditions (like arthritis, asthma or high blood

pressure, for example), the Step Th erapy Program

moves you along a path as outlined below—with

your doctor approving the medications at each step.

First Step: Generic Drugs

Th is fi rst step lets you begin, or continue, treatment

with prescription drugs that have the lowest

copayment. When you submit a prescription that

is not for a fi rst-step, generic drug, you or your

pharmacist should contact your doctor. Only your

doctor can approve and change your prescription

to a fi rst-step drug. You can call Express Scripts for

examples of fi rst-step, generic drugs to discuss with

your doctor. Tested and approved by the U.S. Food

& Drug Administration (FDA), generic drugs can be

eff ective for treating many medical conditions.

Second Step: Brand-Name Drugs

If your path requires medications other than generic

drugs, then the program moves you along to this


next step. If you have already tried a fi rst-step,

generic drug, or your doctor decides you need

a diff erent drug for medical reasons, then your

doctor can call Express Scripts to request a “prior

authorization” for a second-step drug. An Express

Scripts agent will check your plan’s guidelines to see

if the second-step drug is covered. If it is covered,

you pay the applicable copayment, which can be

more than a fi rst-step, generic drug. If it is not

covered, you may need to pay the full price of the

second-step drug.

Exclusions from CoverageNo benefi ts will be paid for the following:

administration or injection of any medication

drugs payable under Workers Compensation Law

drugs required by federal and state mandates

drugs administered in connection with motor

vehicle accidents

prescriptions for animals

drugs prescribed during confi nement in a

hospital, rest home, sanitarium, extended care

facility, skilled nursing facility, or convalescent

hospital that operates on its premises a facility for

dispensing pharmaceuticals (see the “Medical Plan”

chapter, starting on page 11, for information on

benefi ts for drugs you receive while in the hospital)

••••

••

Frequently Asked Questions

Are contraceptives covered?

You have coverage for oral contraceptives when birth control pills are prescribed by a physiciann. Other forms of contraceptives are not covered.

Are erectile dysfunction drugs covered?

Erectile dysfunction drugs will be covered if your physician prescribes them as medically necessary dically necessary and documents that you have been treated for male sexual dysfunction during the last six months.last six mont

If you wish to purchase erectile dysfunction drugs, call Express Scripts. Coverage is limited to six pillss limited tofor each 30-day period.

What if my prescription costs less than the copayment?

If the cost is less than the copayment, you will pay only the cost.

Filing a Claim for Prescription Drug Benefi ts

Note: Th e discussion below applies to “post-service

claims”—claims you submit after you have had

prescription fi lled or refi lled. Requests for required

pre-authorization are also considered claims. See

“Required Pre-Authorizations” earlier in this chapter

and “Claims and Appeals Procedures” on page 57 for

more information on those types of claims.

You will not need to fi le a claim if you purchase

prescription drugs in a participating retail pharmacy

or use the mail-order program, since you will pay

only your copayment.

You will need to fi le a claim for reimbursement if

you have a prescription fi lled or refi lled at a non-

participating retail pharmacy. Contact Express

Scripts for reimbursement forms.


Claims must be fi led within 90 days from the date the charges were incurred.

If you have any questions about submitting your claim, contact Express Scripts.

For information on what to do if you disagree with the decision made in regard to your claim, see “Claims and Appeals Procedures” on page 57.


Member Assistance Program

Problems such as family diffi culties, marital stress,

child and adolescent concerns, illness of a family

member, fi nancial pressure, job stress, or alcohol

and drug abuse may disrupt your life and the lives of

your loved ones.

To help you deal with such problems, the Trustees

have contracted with Th e Wellness Corporation to

provide the Member Assistance Program (MAP).

It is designed to provide prompt, professional

assistance for you and your eligible dependents

when you are having personal and family diffi cul-

ties or need treatment for mental health-related

problems or substance abuse. Th e MAP is available

under both Plan A and Plan B.

FAST FACTS:

Th e Member Assistance Program can help you

deal with life’s problems.

Th e Member Assistance Program works with

the Fund’s medical plan benefi ts for treatment of

mental and nervous conditions or alcoholism and

substance abuse.

Th e accompanying chart is intended to provide a

convenient quick-reference guide to the Member

Assistance Program.

QUICK-REFERENCE GUIDE TO THEMEMBER ASSISTANCE PROGRAM (MAP)

•

•

Th e Wellness Corporation is an organization

of professionals who will provide you and your

eligible dependents with confi dential, professional

assistance. Services are provided 24 hours per day,

seven days per week. Th e Wellness Corporation’s

main objective is to direct you or your dependents

as quickly as possible to the best available resource

for help.

Required Pre-AuthorizationsTo receive any benefi t payments from the Fund for

any treatment of mental or nervous conditions or

alcoholism or substance abuse, you must contact

the Member Assistance Program before you or a

dependent receives ANY treatment. When you

call MAP, one of the MAP professionals will help

you identify and evaluate your problems and, if

necessary, refer you for treatment. If inpatient

treatment is required, you will be referred to a MAP-

approved facility and appropriate treatment plan.

Th e Member Assistance Program (MAP) Benefi ts

are described on page 19.

Claims for Benefi tsClaims for outpatient visits exceeding eight per year

are handled under the medical plan. See page 19 for

more information.

Calls to the Member Assistance Program

No charge.

Outpatient treatment for mental or nervous conditions or alcoholism or substance abuse

(If pre-authorized by MAP and you use the provider to which MAP refers you)

Outpatient treatment beyond the fi rst eight visits under the Member Assistant Program (MAP) and all inpatient treatment are handled under the medical plan—see page 19.

REQUIREMENT TO CONTACT MAP

No benefi ts will be paid by the Fund if you fail to contact the Member Assistance Program before you or your dependents receive any inpatient or outpatient treatment for mental and nervous conditions or substance abuse.


Dental Benefi ts

Your dental benefi ts are provided through Delta

Dental of Massachusetts. Your eligibility for Plan A

or Plan B is determined by the number of hours you

worked during the previous 12-month Qualifying

Period. See the “Eligibility” section for complete

details.

Preventive care (exams, cleanings, etc.) is covered

under Plan A and Plan B. Plan A also includes basic

and major restorative care (from fi llings to dentures)

and orthodontia benefi ts for children under age 19.

In addition, using a network provider can help you

keep your share of the costs down.

Th e accompanying chart is intended to provide a

convenient quick-reference guide to your dental

benefi ts. Be sure to review the “What the Plan

Covers” section for covered services and the

limitations and restrictions of the Plan.

Provision

How It Works

Plan A Plan B



in a PPO Area

Annual deductible per calendar year

No deductible No deductible No deductible No deductible

Diagnostic (Type I) Fund pays 100% Fund pays 100% of usual and customary charges

Fund pays 100% Fund pays 100% of usual and customary charges

Preventive (Type I) Fund pays 100% Fund pays 100% of usual and customary charges


Restorative and Other Basic Services (Type II Services)


The Fund does not cover these services under Plan B. You are responsible for the full cost of the service.

Major Restorative Services (Type III)



Other Dental Services

Dental implants Fund pays 50% of reasonable and customary charges, up to $2,500 per year and $5,000 per lifetime


Orthodontia Lifetime maximum of $2,500.Available to age 19


What the Plan CoversTh e Fund pays benefi ts for the services shown in the accompanying chart, subject to the condition that the services be necessary and appropriate treatment. To be necessary and appropriate, a service must be:

consistent with the prevention of oral disease or with the diagnosis and treatment of those teeth that are decayed or fractured or those teeth where the supporting periodontium is weakened by disease;

in accordance with standards of good dental practice;

not solely for the convenience of you or your dentist;

not more costly than the services that are customarily provided (benefi ts will be based on the least costly method of treatment); and

generally accepted as appropriate for treating your condition.

•

•

•

•

•

ELIGIBLE DENTAL EXPENSES


Covered Services—Limits and Restrictions

Type I: Diagnostic and Preventive(Plan A and Plan B)

Oral examinations (once every six months)

Emergency exams (up to three times in 12 months)

Full-mouth x-rays (once every 60 months)

Bitewing x-rays (once ever 12 months for adults; once every six months for children under age 19)

Single-tooth x-rays (as needed)

Study models and casts and diagnostic casts (once every 60 months)

Prophylaxis (cleaning) (twice per year)

Fluoride treatment (once every six months for children under age 19)

Space maintainers (for children under age 14)

Pit and fi ssure sealants (limited to unrestored permanent molars; once every 48 months for

children through age 15)

Type II: Restorative and Other Basic Services (Plan A only)

Amalgam (metal) fi llings (once every 24 months per surface per tooth)

Composite (white) fi llings (once every 24 months per surface per tooth on front teeth; single surface only on back teeth)

Temporary fi llings (once per tooth)

Stainless steel crowns (once every 24 months for baby teeth only)

Simple or surgical extractions, including impactions

Periodontic scaling and root planing (once in 24 months) per quadrant

Periodontal surgery not provided in a surgical day care nor hospital setting

Periodontal prophylaxis (once every three months following active periodontal treatment)

Root canal therapy (once per tooth)

••

••

••

••

••

•

•

••

•

•

•

•

•

Pulpotomy (to age 14)

Recementing of crowns, inlays, and onlays (once every 12 months per tooth)

Rebase or reline of dentures (once every 36 months)

Denture repairs (once every 12 months, same repair)

Emergency palliative treatment (three occurrences in a 12-month period)

Type III: Major Restorative Services(Plan A only)

Crowns, inlays, and onlays when teeth cannot be restored with regular fi llings due to severe decay or fracture (once every 36 months per tooth)

Complete or partial dentures once within 60 months, fi xed bridges, and crowns when part of a bridge (once every 36 months)

Participating DentistsWhen you need dental care, you may choose a dentist participating in the network or a non-participating dentist. Choosing a participating dentist off ers the following advantages:

Participating dentists have agreed to accept fees determined by Delta Dental Plan. Th at means you will likely incur lower out-of-pocket costs than if you used a non-participating doctor.

A participating dentist will fi le claims directly with Delta Dental. You need only pay the amount due from you when you receive your Explanation

of Benefi ts and your dentist’s bill.

••

•

•

•

•

•

•

•

DEVELOP GOOD DENTAL CARE HABITS

It’s more cost-effective to maintain dental health than it is to regain it. Exercise proper dental hygiene and make use of the preventive services included in your dental benefi ts.

PARTICIPATING DENTISTS

To fi nd a participating dentist, call Delta Dental at 800-872-0500 or 617-886-1234 or visit the Web site www.deltamass.com.


Pre-Treatment EstimatesFor most services, a dentist simply proceeds with treatment. However, in cases when the cost for the treatment is expected to be extensive, you are encouraged to have your dentist request a pre-treatment estimate. Th e result, which will be sent to both you and your dentist, will inform you of any estimated out-of-pocket expenses that you may incur before the services are performed.

You are encouraged to have your dentist submit a request for a pre-treatment estimate for any services that are likely to total $300 or more.

Exclusions from CoverageTh e Fund will not pay benefi ts for the following:

A method of dental treatment more costly than is customarily provided (benefi ts will be based on the least costly method)

services that are meant primarily to change or improve your appearance

replacement of lost or stolen appliances or artifi cial tooth replacements

replacement of dentures more than once every three years or replacement of existing denture or bridgework installed for less than three years unless it is satisfactorily shown that the existing denture or bridgework cannot be made serviceable

oral surgical or periodontal surgery benefi ts rendered in a surgical day care or hospital setting

any professional fees other than the fees of the dentist performing the treatment

services rendered by someone other than a licensed dentist or a hygienist who is employed by a licensed dentist

services related to congenital anomalies

charges that are not necessary, are not recommended and approved by the dentist, or are not reasonable and customary

fees for treatment for an illness or injury arising out of or in the course of your employment

fees that you are not required to pay or services for which you would be eligible for full or partial payment under any state, municipal, or Federal law or regulation

expenses resulting from motor vehicle accidents

expenses incurred after termination of your coverage, including expenses incurred for prosthetic devices inserted after the termination,

•

•

•

•

•

•

•

••

•

•

••

regardless of whether or not the device was ordered before your coverage terminated

repairing or recementing crowns and onlays once within 36 months per tooth

services for temporomandibular joint syndrome (TMJ)

coverage for any illness or injury determined by the Secretary of Veterans Aff airs to have been incurred in or aggravated during performance of service in the uniformed services (the uniformed services and the Department of Veterans Aff airs will provide care for service-connected disabilities).

Filing a Claim for Dental Benefi tsParticipating DentistsIf you use a participating dentist, you will not need to fi le a claim. Simply show your Delta Dental I.D. card when you visit your dentist, then pay the amount due from you when you receive your Explanation of Benefi ts and your dentist’s bill.

Non-Participating DentistsA non-participating dentist may or may not fi le a claim for you. If the dentist asks you to fi le the claim, you can download a form from the Web site www.deltamass.com or use a universal claim form. Your completed claim should be sent to the following address: Delta Dental Plan of Massachusetts, P.O. Box 9695, Boston, MA 02114.

If you use a non-participating dentist, you will be responsible for the dentist’s full charge, minus the amount payable by the Fund.

When Claims Must Be FiledClaims must be fi led within 90 days of the date when you receive the service.

If benefi ts are denied because a participating dentist fails to submit a claim on time, you will not be responsible for paying the dentist for the portion of the dentist’s charge that would have been a benefi t under your plan. You will be responsible for the coinsurance amount or other patient liability, if any. Th is applies, however, only if you properly informed your participating dentist that you were a member by presenting your Subscriber ID Card.

If you have any questions about submitting your claim, contact Delta Dental.

For information on what to do if you disagree with the decision made in regard to your claim, see “Claims and Appeals Procedures” on page 57.

•

•

•


Vision Care Benefi ts

Your vision care benefi ts are provided through Davis

Vision. You may obtain services from more than

100 participating providers throughout the New

England area.

FAST FACTS:

Under Plan A and Plan B, you and your eligible

dependents are entitled to receive a comprehen-

sive eye examination, new spectacle lenses, and an

eyeglass frame once every 24 months.

Also, under both plans children under age 19

will be eligible for these benefi ts once every 12

months.

How the Plan WorksYou may use either a network or non-network

provider for your vision care under Plan A and Plan

B. If you use a network provider, you will not have

to pay anything (unless you order items that are not

covered—see “Exclusions from Coverage” later in this

chapter). For both Plans, if you use a non-network

provider, the benefi ts paid by the Fund will be

limited to the reimbursement allowances described

in this chapter under the “Optional Plan” section.

•

•

What the Plan CoversYour vision care benefi ts cover an exam and

eyeglasses and other services as shown in the

following pages.

You may select two complete pairs of eyeglasses

(one for near vision, one for distance vision) in lieu

of receiving a bifocal.

Your benefi t includes the following types of lenses at

no extra cost:

glass or plastic single vision, bifocal or trifocal

lenses;

oversize and over diopter (high power) lenses;

PGX (photosensitive) glass lenses;

glass grey #3 prescription sunglasses lenses;

progressive addition lenses; and

supershield coating for both single vision and

multi-focal lenses.

Polycarbonate lenses will be provided to children

and monocular patients without charge.

Using a Davis Vision ProviderIf you select a Davis Vision provider, he or she will

provide detailed information about the options to

which you are entitled.

Call a Davis Vision doctor of your choice and

schedule an appointment. Your doctor’s offi ce will

determine your eligibility. If you would like to verify

your eligibility for vision benefi ts prior to calling for

an appointment, call 800-999-5431.

•

•••••

RETIRED UNION MEMBERS

If you are a retired Maine, New Hampshire, Vermont, or Massachusetts Union member who maintains his Union membership, you and your eligible dependents are eligible for the vision care benefi ts described in this chapter. This benefi t is maintained by the Massachusetts and Maine, New Hampshire and Vermont Laborers’ District Councils, which have contracted with the Fund Offi ce to provide this benefi t.

HOW TO FIND A DAVIS VISION PROVIDER

To locate the Davis Vision providers nearest you,call the automated Provider Locater Systemat 800-999-5431 or go to the Web sitewww.davisvision.com.


The Optional PlanYou may, if you prefer, go to a non-network

optometrist, ophthalmologist, or optician to obtain

your refraction examination and/or glasses.

If you choose a non-network optometrist,

ophthalmologist or optician, you will be reimbursed

up to the maximum allowance set forth in the

following schedule of benefi ts:

SCHEDULE OF VISION CARE BENEFITS

Exclusions from CoverageTh e Fund will not pay any benefi ts for the following:

exams or materials provided more frequently than

at the intervals specifi ed in this chapter;

medical or surgical treatment of the eye (However,

if the examination indicates the need for medical

or surgical treatment, such care may be covered

under the medical plan);

duplicate glasses, replacement of lost or broken

glasses, such as prescribed or plain sunglasses, or

for contact lenses, tinting, or types of lenses not

listed above (All such items, if furnished, must be

paid for by you); or

services for which benefi ts are not payable

according to the “General Limits and Exclusions”

starting on page 45.

Filing a Claim for Vision Care Benefi ts

Davis Vision Providers

If you use a Davis Vision provider, you will not need

to fi le a claim for benefi ts. If you order any items not

covered (see “Exclusions from Coverage” ), you will

need to pay the cost of those items. Otherwise, your

exam and eyeglasses will be covered in full.

Optional Plan Providers

If you use an optional plan provider, you will need

to pay the provider in full and then fi le a claim form

for the reimbursable amount. Th e Fund Offi ce will

send you a standard claim form to be fi lled out by

you and the person(s) performing the services upon

request. Reimbursements are sent to the member

not the provider. Your completed claim form should

be sent to Fund Offi ce.


Claims must be fi led within 90 days from the date

the charges were incurred.

If you have any questions about submitting your

claim, contact the Fund Offi ce.

•

•

•

•

Refraction and pathological examination by an optometrist, including the fi tting of glasses and the verifi cation of prescrip-tion lenses

Maximum $20.00

Complete medical eye examination (exclusive of treatment), refraction, and pathological examinations by an ophthalmologist, including the fi tting of glasses and the verifi cation of prescrip-tion lenses

Maximum $30.00

Frame(when prescription lenses are required)

Maximum $20.00

Lenses: Single Pair

Single vision $15.00 $30.00

Bifocal $20.00 $40.00

Trifocal $25.00 $50.00

(No benefi ts are allowed for Plano, non refractive lenses, contact lenses, or non-prescription sunglasses)

Repair or replacement of broken or damaged frame or lenses, if it can be satisfactorily shown that the existing frame or lenses cannot be made serviceable:

Frame $10.00

Lens or Lenses as above


Weekly Accident and Sickness Benefi ts

Th e weekly accident and sickness benefi ts is for members only and it can help replace lost income when an injury or illness prevents you from working. Th is benefi t provides the same level of coverage and is available under both Plan A and Plan B.

FAST FACTS:Weekly accident and sickness benefi ts are available only for disabilities that are not work-related or for which car insurance is compensating you for lost wages.

Weekly accident and sickness benefi ts are available to eligible, active participants only—not to dependents.

Eligibility for Payment of Benefi tsYou will be eligible for the Plan’s weekly accident and sickness benefi ts if, while covered under the Plan, you become totally disabled and unable to work because of

any injury not arising out of or in the course of your employment;

any disease not entitling you to benefi ts under any Workers’ Compensation;

occupational disease law, or similar legislation; or

any injury or disease not entitling you to auto-mobile insurance wage continuation payments.

It is not necessary to be confi ned to your home to collect benefi ts, but you must be under the care of a physician.

When Payment of Benefi ts StartsPayment will start as of the fi rst day of disability, if the disability is due to an accident, or the eighth day of the disability, if the disability is due to an illness.

No disability will be considered to have started until you have been treated personally by a physician.

Pregnancy-Related DisabilityIf you become totally disabled and medically unable to work because of pregnancy, childbirth, or

•

•

•

•

••

miscarriage, weekly accident and sickness benefi ts are payable from the eighth day of disability on the same basis as any other illness.

How Long Payments Can ContinueYou may receive weekly accident and sickness benefi ts for up to 13 weeks for any one continuous period of disability that is due to the same or related cause or causes, as long as you remain eligible. Successive periods of disability separated by less than two weeks of continuous active employment with an employer who makes contributions on your behalf to the Fund will be considered one continuous period of disability, unless they arise from diff erent and unrelated causes, in which case a return to active work for at least one full day is required.

Limits and ExclusionsNo benefi ts are payable for the following:

any day you are not under the care of a physician,

any day you are receiving compensation or performing work of any kind, anywhere, for compensation or profi t,

any day you are released by your physician to engage in work of any kind,

a disability due to accidental bodily injuries arising out of and in the course of your employment,

those days for which you are receiving compensa-tion for lost wages from automobile insurance or its equivalent, Workers’ Compensation, unemployment compensation, or any company sponsored pension plan, or

services for which benefi ts are not payable according to the “General Limits and Exclusions” starting on page 45.

Filing a Claim for Weekly Accident and Sickness Benefi tsYou and your doctor must FULLY complete a Provider’s Green Claim Form and return that completed form to the Fund Offi ce.

When Claims Must Be FiledClaims must be fi led no later than 90 days after the date your disability began.

If you have any questions about submitting your claim, contact the Fund Offi ce.

••

•

•

•

•

Weekly Accident and Sickness Benefi ts

Provide you with a payment of up to $39 a day or $273 per week for up to 13 weeks. Benefi ts begin the 1st day for a disability caused by an accident or on the 8th day for a disability caused by illness.


Life Insurance Benefi ts

In the event of your death from any cause—on the job or off —while you are covered under Plan A or Plan B, a death benefi t of $10,000 will be paid to your named benefi ciary.

FAST FACTS:

Th e amount of the life insurance benefi t is $10,000.

Only eligible, active participants are eligible for life insurance coverage (not dependents).

Life Insurance Benefi t

Pays your benefi ciary $10,000 in the event of your death from any cause.

Your Benefi ciaryYour benefi ciary for this benefi t is the designated benefi ciary that the Massachusetts Laborers’ Health and Welfare Fund has on fi le for you for your health and welfare benefi ts.

You may change your benefi ciary at any time, provided you complete a Benefi ciary Designation Form.

If you do not have a designated living benefi ciary when you die, the insurance company and/or the Trustees will pay the proceeds of your life insurance to your estate.

If You Become Totally and Permanent DisabledIf you become totally and permanently disabled while eligible before you reach age 60, your life insurance coverage will be continued at no cost to you. You must complete and fi le an “Application for Total and Permanent Disability” with the Fund Offi ce within 90 days of when the disability starts. Application forms are available at the Fund Offi ce.

Th e insurance company will also require periodic proof that you continue to be totally and permanently disabled.

•

•

Extended Death Benefi tIf you should die within 31 days from the date your insurance is terminated, the full amount of life insurance will be payable to your named benefi ciary.

Conversion PrivilegesWithin 31 days following termination of your eligibility under the Plan, you may convert your group life insurance to an individual life insurance policy by mailing an application to Th e Union Labor Life Insurance Company.

To convert to an individual life insurance policy,contact the Union Labor Life Insurance Company at: 202-682-0900, 111 Massachusetts Avenue, N.W., Washington, D.C. 20001.

Since each participant is expected to know the eligibility rules of this Fund, and since it is not always possible for the Fund Offi ce to send a notice of termination in suffi cient time for a terminated participant to exercise the conversion privilege within the 31 day limit, each participant who desires to convert to an individual policy should, for his own protection, make it his personal responsibility to apply for conversion of the life insurance coverage within the 31 day period.

Filing a Claim for Life Insurance Benefi tsIn the event of your death, your benefi ciary should contact the Fund Offi ce to obtain a life insurance claim form. Th e completed claim form should be returned with any required documentation to the Fund Offi ce.

Deadline for Submission

When submitting a claim, your benefi ciary should allow time for the Fund Offi ce to transmit the claim to the insurance company. Union Labor Life Insurance Company should receive notice of the claim within 90 days of the death or as soon thereafter as is reasonably possible.

If your benefi ciary has any questions about submitting the claim, he or she should contact the Fund Offi ce.

BENEFITS FOR RETIREESIf you are a retiree, see page 36 for information on the death benefi t payable when an eligible retiree dies.


Accidental Death and Dismemberment Benefi ts (AD&D)

If you die as the result of an accident, your benefi ciary

may receive an additional death benefi t. If you lose a

limb or an eye, a benefi t may be paid to you.

FAST FACTS:

AD&D benefi ts are payable when an accident results in your death or causes you to lose an arm or leg or sight.

Only eligible, active participants are eligible for AD&D benefi ts coverage (not dependents).

AD&D benefi ts are paid in addition to any other benefi ts payable under the Plan.

Th is benefi t is available under both Plan A and Plan B.

AD&D BENEFITS

Description of Loss Benefi t Payable

Your death $10,000 (Paid to your benefi ciary or estate)

Loss of two of your limbs $10,000 (Paid to you)

Loss of sight in both of your eyes $10,000 (Paid to you)

Loss of one of your limbs and sight in one of your eyes

$10,000 (Paid to you)

Loss of one of your limbs $5,000 (Paid to you)

Loss of sight in one of your eyes $5,000 (Paid to you)

Loss of limb means dismemberment by severance at or above the wrist or ankle joint. Loss of sight means the entire and irrecoverable loss of sight.

How the Benefi ts WorkAD&D benefi ts are payable as shown in the chart above for losses that are the direct result of bodily injuries sustained solely through accidental means while participants are insured under the Plan. Th ey are payable whether or not the accident occurs during the course of your employment.

Th e loss must occur within 90 days from the day of the accident.

•

•

•

•

If you suff er more than one of the losses shown in the chart as the result of any one accident, no more than $10,000 will be payable.

Your Benefi ciaryYour benefi ciary for the accidental death benefi t is the same benefi ciary you have for your life insurance under the Massachusetts Laborers’ Health and Welfare Fund.

You may change your benefi ciary at any time, provided you notify the Fund Offi ce and complete in writing the proper form.

If you do not have a designated benefi ciary, the insurance company and/or the Trustees will pay the accidental death benefi t (if applicable) to your estate.

Limits and ExclusionsNo payment will be made for death or any loss resulting from or caused directly, wholly, or partly by:

bodily or mental infi rmity, ptomaines, bacterial infections (except infections caused by pyogenic organisms that occur with and through an accidental cut or wound), or disease or illness of any kind; or

services for which benefi ts are not payable according to the “General Limits and Exclusions” starting on page 45.

Filing a Claim for Accident Death and Dismemberment (AD&D) Benefi tsYou or your benefi ciary should contact the Fund Offi ce to obtain an AD&D benefi ts claim form. Th e completed claim form should be returned with any required documentation to the Fund Offi ce.

Deadline for Submission

When submitting a claim, please allow time for the Fund Offi ce to transmit the claim to the insurance company. Union Labor Life Insurance Company should receive notice of the claim within 90 days of the loss or as soon thereafter as is reasonably possible.

If you or your benefi ciary has any questions about submitting the claim, you should contact the Fund Offi ce.

•

•


Retiree Benefi ts

You may be eligible for continuing your medical and dental benefi ts after you retire. If you are a retired Union member and maintain your membership, you and your dependents are covered under the vision benefi t provided by the Massachusetts Laborers’ District Council and the Maine, New Hampshire and Vermont District Council.

FAST FACTS:You can continue medical and dental coverage for yourself and your eligible dependents by making payments to the Fund Offi ce. Th e Fund Offi ce shares in the cost for retiree coverage.

If you were enrolled in Plan A COBRA coverage, you may elect Plan A retiree self-pay coverage.

If you were enrolled in Plan B COBRA coverage, you may elect Plan B retiree self-pay coverage.

Your benefi ciary may receive a death benefi t when you die.

The Retiree’s Self-Pay Medical ProgramEligibilityYou may continue your medical and dental coverage under the Massachusetts Laborers’ Health and Welfare Fund if:

you have been continuing coverage at your own cost under COBRA (see page 5);

you are receiving a Pension from the Massachu-setts Laborers’ Pension Fund;

you make an election to enroll in the Retirees’ Self-Pay Medical Program; and

you are not eligible for Medicare.

Who Can Be CoveredYou may elect to cover yourself and your eligible dependents. Only those who are COBRA participants can be covered under the Retirees’ Self-Pay Medical Plan.

If you elect to cover yourself only at the time you elect to enroll in the Retiree Self-Pay Medical Program, you will not be allowed to later cover your dependents.

•

•

•

•

•

•

•

•

What Benefi ts Are IncludedYou may be eligible for medical or medical and dental coverage as follows:

Plan A retiree self-pay plan if you were enrolled in Plan A COBRA

Plan B retiree self-pay plan if you were enrolled in Plan B COBRA

You will not be eligible for weekly accident and sickness benefi ts, life insurance, accidental death and dismemberment, or vision benefi ts regardless of which plan of benefi ts you elect.

How Long Coverage Will LastCoverage under the Retirees’ Self-Pay Medical Plan will terminate on the earliest of the following dates:

when timely payment is not made;

when a covered individual becomes eligible for Medicare; or

(for dependent children) when the child no longer meets the defi nition of a dependent under the Health and Welfare Plan.

Retiree Vision Care & Hearing Benefi ts You and your eligible dependents may participate in the vision and hearing programs if you are a retired member of a construction local of the Massachu-setts Laborers’ District Council who maintains his or her Union membership with the Laborers’ International Union of North America; and made dues contributions through your working dues into the retiree benefi t account maintained by the Massachusetts Laborers’ District Council.

Retired members and their eligible dependents in the Maine, New Hampshire and Vermont construc-tion locals who maintain their Union membership will also be eligible for vision benefi ts only.

Retiree Death Benefi t To be eligible for the retiree death benefi t, you must:

be retired from the labor market, as that term is defi ned under the rules and regulations of the Massachusetts Laborers’ Pension Plan; and

have been covered by the Fund for three out of the last fi ve years prior to date of your retirement.

Th e amount of the retiree death benefi t is $3,000. Th is amount will be paid to your benefi ciary in the event of your death.

•

•

••

•

•

•ELIGIBLE DEPENDENTSSee page 3 for information on who is an eligible dependent under the Plan.


Life Events

Th is chapter provides information on what to do if you experience an event that might involve your benefi ts.

FAST FACTS:

Th e following life events may involve your benefi ts:

Getting married

Adding a child to your family

Divorcing or legally separating from your spouse

A child’s losing eligibility for benefi ts

Serving in the military

Taking a medical or family leave

Moving

Becoming disabled

Terminating your employment

Retiring

Death

If You Get MarriedIf you get married, you may add your new spouse to your health care coverage. You may also want to designate your new spouse as your benefi ciary for your life insurance and Accidental Death and Dismemberment (AD&D) benefi ts.

•••••••••••

If You Add a Child to Your FamilyYou may add any eligible dependent children to your health care coverage. You may also want to designate a new child as benefi ciary or one of your benefi ciaries for your life insurance and AD&D benefi ts.

Contact the Fund Offi ce within 30 days of the date you wish to add a child to your health care coverage.

Provide the Fund Offi ce with a copy of the child’s birth certifi cate (long form).

If you wish to change your benefi ciary designation for your life insurance and AD&D benefi ts, request a benefi ciary designation form from the Fund Offi ce or visit the Web site at www.MLBF.org.

If You Divorce or Legally Separate from Your SpouseYour ex-spouse may be eligible for continuation

coverage under the conditions described on page 8.

Contact the Fund Offi ce within 30 days of your marriage to add your new dependent(s) to your health care coverage. Failing to notify the Fund Offi ce within 30 days of your remarriage will result in you being responsible to reimburse the Fund for any payments made on behalf of that dependent.

Send the Fund Offi ce an offi cial copy of your marriage certifi cate and an offi cial copy of your spouse’s birth certifi cate.

If you wish to designate your new spouse as benefi ciary for your life insurance and AD&D benefi ts, request a benefi ciary designation form from the Fund Offi ce or visit the Web site at www.MLBF.org.

CHECKLIST

CHECKLIST

Contact the Fund Offi ce within 30 days to have your spouse removed from your benefi ts coverage, if applicable.

Send the Fund Offi ce a copy of your court decree with agreements.

Update your benefi ciary information as necessary.

If your ex-spouse’s address has changed because of the divorce or separation, please inform the Fund Offi ce in writing of the new address.

CHECKLIST


If You MoveTh e Fund Offi ce sends notices by mail of updates to procedures, eligibility, explanation of benefi ts and other important matters relating to the Plan. Th ese notices are sent to the address that’s on fi le at the Fund Offi ce.

If You Become DisabledIf you are unable to work because of a disability that is not work-related and for which you will not receive car insurance wage continuation payments, you may be eligible for weekly accident and sickness benefi ts (replacement income of up to $273 per week for up to 13 weeks). See page 33 for more information.

Th e Plan also has two other provisions that may be of interest to you:

Th e Fund may continue to pay medical benefi ts for the disability even after you lose eligibility for benefi ts coverage under the Plan (see page 22);

If you become totally and permanently disabled before you reach age 60, your life insurance coverage may be continued at no cost to you (see page 34).

•

•

If a Child Loses Eligibility for CoverageCoverage for a child who ceases to be an eligible

dependent will end when that child attains the age

of 19 or 23 if a full-time student. Your child may

continue health care coverage under COBRA for up

to 36 months.

If You Enter Military ServiceIf you enter active military service in the uniformed

services of the United States while eligible for Fund

coverage, you and your eligible dependents can

continue to be covered as long as your eligibility

continues.

If the child wishes to continue benefi ts coverage under the Fund, he or she may do so by electing COBRA continuation coverage. It’s your responsibility to notify the Fund Offi ce if you wish to continue coverage through COBRA. See page 5 for more information about COBRA.

The Fund Offi ce will send COBRA information to the address it has on fi le for you. If your child resides at another address, you are responsible for getting the COBRA information to him or her.

CHECKLIST

Submit a copy of your military induction and separation orders or DD Form 214 to the Fund Offi ce upon entering/ending active military service.

Make sure you adhere to the provisions for returning to covered employment after your military service ends.

CHECKLIST

If you think you have a disability that qualifi es for weekly accident and sickness benefi ts, contact the Fund Offi ce regarding applying for benefi ts.

If you are disabled and choose extended benefi ts for a particular illness (see page 22), you may lose your rights to elect COBRA.

If you are interested in continuing your life insurance coverage at no cost to you, complete and fi le an “Application for Total and Permanent Disability” with the Fund Offi ce within 90 days of when the disability starts. Application forms are available at the Fund Offi ce.

CHECKLIST

If you move, it is your responsibility to let the Fund Offi ce know in writing about your change of address or update your address in the Member Dashboard on the Web site atwww.MLBF.org.

CHECKLIST


If Your Eligibility EndsWhen your eligibility ends, you and your eligible

dependents may continue your health care coverage

for up to 18 months (29 months if the Social

Security Administration fi nds one of you disabled)

under COBRA.

After COBRA ends, you may continue health care

coverage under the Retirees’ Self-Pay Medical

Program, if you qualify.

If you wish, you may convert your life insurance to

an individual policy.

•

In the Event of Your DeathIn the event of your death, your eligible dependents

may continue their health care coverage for up to

36 months under COBRA. Your benefi ciary will

be eligible for the proceeds of your life insurance

coverage and, if your death was the result of an

accident, the accidental death benefi t included in

your AD&D benefi ts.

To continue your health care coverage under the Fund, you must enroll in COBRA continuation coverage within 60 days of when notice of your COBRA rights arrives from the Fund Offi ce or the date your coverage would otherwise end, whichever is later. See page 5 for more information about COBRA.

If you wish to convert your life insurance to an individual policy, you must apply directly to the insurance company within 31 days of when your eligibility for coverage under the Fund terminates. See page 34 for more information about conversion to an individual policy.

CHECKLIST

To continue their health care coverage under the Fund, your dependents must enroll in COBRA continuation coverage within 60 days of when notice of your COBRA rights arrives from the Fund Offi ce or the date your coverage would otherwise end, whichever is later. (The COBRA information will be sent to the address on fi le for you, so they should notify the Fund Offi ce if it needs to be sent to a different address.) More information about COBRA can be found starting on page 5.

Your benefi ciary should contact the Fund Offi ce to fi nd out how to apply for the life insurance benefi t and, if applicable, the accidental death benefi t.

CHECKLIST


Coordination of Benefi ts

Coordination of health care benefi ts conserves your

health care dollars and protects the entire Plan from

unnecessary increases in cost.

FAST FACTS:

Coordination of Benefi ts prevents duplicate

benefi t payments when a person is covered under

more than one plan.

Rules for order of payment determine which plan

pays fi rst.

Quite frequently, because both husband and wife

are working, members of a family could be covered

under more than one plan of group health care

benefi ts. Th ere are many instances of duplication of

coverage—for example, two plans paying benefi ts

for hospital and medical expenses. For that reason

a Coordination of Benefi ts provision has been

adopted that will coordinate the health care benefi ts

payable by the Plan with similar benefi ts payable

under other plans.

How Coordination of Benefi ts WorksUnder the Coordination of Benefi ts provision, if you

or any of your dependents is also insured or entitled

to health coverage under any other group plan, the

total payment received for any one person from all

such programs combined may not amount to more

than 100% of the “allowable expenses.”

“Allowable expense” means any necessary,

reasonable, and customary item of expense, at least

a part of which is payable by any one of the plans

that covers the person for whom a claim is made.

When the benefi ts from a plan are in the form of

services, not cash payments, the reasonable cash

value of each service is both an allowable expense

and a benefi t paid.

Benefi ts are reduced only to the extent necessary to

prevent an individual from recovering more money

than he was charged and required to pay.

•

•

For purposes of Coordination of Benefi ts, the word

“plan” means any of the following plans that provide

full or partial health benefi ts for services on an

insured or self funded basis:

any group practice plans, HMO or prepayment plans;

union welfare plans, employer organization plans,

or labor management trustee plans;

governmental programs or coverages required

or provided by law (other than governmental

program coverage that is not allowed by law to

coordinate); and

Medicare, title XVII of the Social Security Act of

1965, as amended, to the extent permitted by law.

“Plan” will apply separately to each policy, contract,

agreement, or other plan for benefi ts or services.

It will also apply separately to that part of such a

policy, contract, agreement, or plan that reserves

the right to consider the benefi ts or services of other

plans in determining its benefi ts and that part which

does not.

Which Plan Pays FirstTh e plan under which benefi ts are payable fi rst is the

primary plan. All other plans are called secondary

plans. Th e secondary plans pay any remaining

unpaid allowable expenses. No plan pays more than

it would have paid without this provision.

Th e rules below determine which plan’s benefi ts are

payable fi rst:

A plan that does not have a Coordination of

Benefi ts provision is always primary and pays

fi rst.

If an individual is covered as a participant under

two plans, the plan that has covered him the

longer is primary.

••

•

•

•

•

PRESUMPTION OF OTHER COVERAGEIf other coverage is available, this Plan will coordinate its benefi ts with that coverage even if you or your spouse fails to accept the other coverage.


A plan that covers the individual as an active

participant pays before a plan that covers the

individual as a laid off member or as a retiree.

A plan that covers the individual as a participant

pays before a plan that covers the individual as a

dependent.

Th e rules to determine which plan’s benefi ts are

payable fi rst when a dependent child is covered

under two or more plans are as follows:

If the parents are not divorced or separated, the

plan that covers the parent whose date of birth

occurs earlier in the calendar year, excluding year

of birth, pays fi rst. If the birthday of both parents

occurs on the same date, the plan that has covered

the parent for the longer period of time pays fi rst.

If the individual is a dependent child of separated

or divorced parents, the “order of payment” used

to determine the primary plan is as follows:

Th e plan of the natural parent with custody of

the child pays fi rst.

If a court order makes one parent fi nancially

responsible for the health care expenses of the

child, that parent’s plan will pay fi rst.

If you or any of your eligible dependents elect

to be covered by an employer-sponsored Health

Maintenance Organization that is determined to be

the primary payer, no benefi ts are payable under this

Plan. Also, if you or any of your eligible dependents

violate the provisions of the Health Maintenance

Organization (e.g. neglect to utilize the facilities of the

HMO), no benefi ts will be payable under this Plan.

Finally, if the Fund Offi ce has made payment of any

amount that is in excess of that permitted by these

Coordination of Benefi ts rules, the Fund Offi ce has

the right to recover such amount from any party

that has received such overpayment.

•

•

•

•

–

–

Coordination with Other Funds Under Reciprocal Arrangements

If you are entitled to benefi ts under more than one

Laborers’ Fund in New England without combining

the hours from each, the fund having the earliest

eligibility will be primary and the other fund will be

secondary.

Coordination with Medicare

Generally, anyone age 65 or older is entitled to

Medicare coverage. Anyone under age 65 who is

entitled to Social Security Disability Income Benefi ts

is also entitled to Medicare coverage after a waiting

period.

If you or your dependent are covered by this Plan

and by Medicare and you retain your coverage

under this Plan, your health care coverage will

continue to provide the same benefi ts as long as you

have Plan eligibility, with this Plan paying fi rst and

Medicare paying second.

If you become totally disabled and entitled to

Medicare while you have Plan eligibility, this Plan

pays fi rst and Medicare pays second. If you become

totally disabled and entitled to Medicare, you will

no longer be considered to have Plan eligibility if

you are receiving coverage under this Plan through

COBRA continuation coverage or retiree health

coverage, and Medicare will pay fi rst and this Plan

will pay second. Generally, if an eligible dependent

under this Plan becomes totally disabled and

entitled to Medicare, for that eligible dependent this

Plan pays fi rst and Medicare pays second.

If, while you have Plan eligibility, you or any of your

covered dependents becomes entitled to Medicare

because of end-stage renal disease (ESRD), this Plan

will pay fi rst and Medicare will pay second for 30

months starting the earlier of the month in which

Medicare ESRD coverage begins or the fi rst month

in which the individual receives a kidney transplant.

Th en, starting with the 31st month after the start of

Medicare coverage, Medicare will pay fi rst and this

Plan will pay second.

DUTY TO REPORT OTHER COVERAGE

You are required to report any other group health coverage that covers you or an eligible dependent on any claim submitted to the Fund Offi ce.


The Fund’s Right to Reimbursement

Reimbursement and Subrogation

Th ird-Party Liability

Th e Plan does not cover, nor is the Fund liable for,

any health expenses incurred by you or an eligible

dependent as a result of an accident or injury for

which one or more third parties are or may be legally

liable. You or one of your eligible dependents may

incur medical expenses in a situation where a third

party—for example, Workers’ Compensation, the

driver of an automobile, or an auto insurance or other

liability carrier—may be liable or held responsible for

their payment. At their discretion, the Trustees may

pay some or all of the health expenses even where

a third party liability may exist. In this situation,

the Fund has all rights of recovery that you or your

dependents would have, including the right to bring

suit in your or your dependents’ name.

You and your dependents must cooperate with

the Fund to secure the recovery of the payment.

You and your dependents will give no release or

discharge with respect to any rights of recovery and

will do nothing to prejudice those rights without

the written consent of the Fund. If you or your

dependents recover any amounts from the third

party or its insurer, the Fund must be reimbursed

from the recovery for benefi ts that it has paid.

Before the Fund will pay benefi ts for expenses that

may be the responsibility of a third party, you, your

attorney and your dependents will be required to sign

an agreement affi rming the obligation to reimburse

the Fund from the proceeds of any recovery. Th e

obligation to reimburse the Fund, however, does not

depend on whether a reimbursement agreement

actually is signed. By accepting the payment of

benefi ts, you and your dependents agree to comply

with all of the Fund’s reimbursement policies and

acknowledge its subrogation and lien rights.

Th e Fund will withhold payment on any claim when

it believes that a third party may be responsible until

a reimbursement agreement is executed. You, your

attorney and your dependents must execute the

reimbursement agreement and submit it for receipt

by the Fund Offi ce within 90 days of the date of the

accident or injury. If it is not reasonably possible

to submit the executed reimbursement agreement

within 90 days, it must be received by the Fund

Offi ce as soon as reasonably possible but in no event

later than one year from the date of the accident or

injury. If you or your dependents fail to comply with

this obligation to sign and submit the reimburse-

ment agreement within the deadline, the Fund will

deny all claims relating to the accident or injury. Th e

Fund will further seek reimbursement of any claims

paid relative to this accident or injury.

If you or your dependent asserts a claim of any nature

concerning an injury or condition for which the

Fund has paid or may pay benefi ts, the Fund must

be promptly notifi ed of all the details. If you or your

dependent retains an attorney in connection with

an injury or condition for which the Fund has paid

or may pay benefi ts, the attorney must be promptly

notifi ed of the Fund’s subrogation and reimburse-

ment policies and provided with a copy of the

reimbursement agreement, and the Fund must be

promptly notifi ed of the attorney’s name and address.

Th e attorney will not distribute any amounts subject

to reimbursement or any disputed amounts, but will

hold them in a client trust account until all disputes

are fi nally resolved and the Fund is reimbursed.

Th e Fund has an equitable lien on that portion of

any recovery from a third party that you or your

dependents are obligated to reimburse, and that

lien right will have fi rst priority over any other lien

or claim against the recovery. Th e Fund’s lien exists

regardless of the extent to which the actual proceeds

of the recovery are traceable to particular funds


or assets. In addition, that portion of a recovery

from a third party that you or your dependents are

obligated to reimburse is and will be considered

to be an asset of the Fund as of the moment the

recovery is transferred by the third party, whether

or not it is actually received by the Fund, and title to

that portion will vest immediately in the Fund.

You, your dependents and those acting on your or

their behalf including attorneys will be fi duciaries to

the Fund with respect to the portion of any recovery

that is subject to reimbursement until it is actually

received by the Fund. You, your dependents, and

those acting on your or their behalf will hold such

portion of any recovery in constructive trust for the

benefi t of the Fund, will place and maintain such

portion of any recovery or any disputed portion

of the recovery in a separate segregated account

until your or your dependents’ reimbursement and

fi duciary obligations to the Fund are satisfi ed, and

will immediately notify the Fund of the location and

account number of any account in which the portion

of the recovery that is subject to reimbursement is

deposited or transferred.

If you or a dependent fails to comply with any of the

Fund’s reimbursement or subrogation policies, the

Fund may deny all claims concerning the underlying

injury or condition. If you or a dependent fails

to reimburse the Fund or to pay the Fund’s costs,

expenses and attorneys fees incurred in litigation, the

Fund may withhold payment of future benefi ts from

you as well as from all of your dependents, regardless

of whether or not the benefi ts are related to the

underlying injury or condition, up to the amount

due plus interest, as well as the amount of any costs,

expenses, and attorneys fees. Th e Fund may withhold

future benefi ts regardless of whether the Fund has

sought judicial enforcement of its rights.

Subrogation

If you or your dependent is involved in an

automobile or any motor vehicle accident covered

by an insurance policy, the insurance carrier will

initially be liable for lost wages, medical, surgical,

hospital, and related charges and expenses up to the

greater of the maximum amount of basic benefi t

required by applicable law or the maximum amount

of the applicable insurance coverage in eff ect.

Th ereafter, the Plan will consider any excess charges

and expenses under the applicable provisions of the

respective Plan in which you are provided coverage.

Th e Fund will have the right to bring suit in the

name of you or your dependents against any party

that may be liable for the sums paid by the Fund for

medical benefi ts.

You or your dependents exclusively may bring

suit against any liable party within seven months

of the date of injury for which benefi ts are paid.

After seven months have elapsed from the date of

injury for which benefi ts have been paid, the Fund

may also bring suit in the name of you or your

dependents.

For any recovery obtained by you or your

dependent, the Fund’s share of the recovery, whether

through suit or settlement, will be determined based

on the following method:

First, you or your dependent’s reasonable attorney’s

fees (not to exceed 33% of the total recovery) will be

deducted from the total recovery.

If the Total Adjusted Recovery is:

Then the Fund’s Share of Recovery is:

1. Equal or less than the benefi ts paid by the Fund

50% of the benefi ts paid by the Fund

2. Greater than the benefi ts paid by the Fund, but less than twice or equal to twice the benefi ts paid by the Fund


3. Greater than twice the benefi ts paid by the Fund


Any amounts remaining thereafter will be paid to

you or your dependent.

You and your dependents must execute instruments

and papers, furnish information, provide assistance

and take all other necessary and related action as the

Fund may request to facilitate satisfaction of its sub-

rogation as well as its reimbursement and lien rights.

Upon the Fund’s request, you, your attorney and

your dependents will execute an assignment of your

and their rights under any uninsured/underinsured

portion of any automobile liability insurance policy

in order to satisfy an obligation to reimburse the

Fund and satisfy the Fund’s subrogation and lien

rights as described above.


Qualifi ed Medical Child Support Orders (QMCSOs)

Th is section describes the Qualifi ed Medical Child

Support Orders (QMCSOs) under which the Plan

may be directed to enroll a dependent child of yours

in coverage.

A QMCSO is any court judgment, decree, or order

(including the approval of a settlement agreement)

that creates or recognizes an alternate recipient,

such as a child or stepchild, to be eligible under this

Plan. As required by ERISA, the Plan will recognize

a QMCSO that:

provides for child support of child(ren) under the Plan;

provides for health coverage to child(ren) under state domestic relations law; (including a community property law); and

relates to benefi ts under this Plan.

To qualify, a QMCSO must include the names

and mailing addresses of you and each alternate

recipient covered by the order. It must also provide a

reasonable description of the type of coverage to be

provided and specify the name of the plan and the

period to which the order applies.

•

•

•

A QMCSO may not require the Plan to provide any

type or form of benefi ts or option which it does

not otherwise provide, except as necessary to meet

certain requirements of the Social Security Act

relating to the enforcement of state child support

laws and reimbursement of Medicaid.

Once the Fund Offi ce receives a QMCSO, it will

promptly notify you and each alternate recipient

named in the order in writing, including a copy

of the order and of the Plan’s procedures for

determining whether the order qualifi es as a

QMCSO. Th e Fund Offi ce will also allow the

alternate recipients to designate representa-

tives to receive copies of notices sent to them.

Finally, the Fund Offi ce will determine within a

reasonable time whether the order qualifi es, notify

the appropriate parties of the determination, and

ensure that the alternate recipients are treated as

benefi ciaries under ERISA reporting and disclosure

requirements.

Coverage under a QMCSO will start on the date

specifi ed in the order.

If you would like a copy of the Plan’s procedures for

handling Qualifi ed Medical Child Support Orders,

please contact the Fund Offi ce. A copy will be

provided free of charge.


General Limits and Exclusions

In addition to any limits or specifi c exclusions

included in the chapters on diff erent benefi ts

earlier in this booklet, there are general limits and

exclusions that apply to all benefi ts. No payment will

be made for expenses incurred for you or any one of

your eligible dependents for the following:

Services, supplies, or treatments that are not

prescribed, recommended, or approved as

medically necessary. Th is exclusion also applies

to any hospital confi nement or any part of a

confi nement;

fees that are in excess of the reasonable and

customary charges for services, supplies, or

treatment;

cosmetic surgery, unless required because of:

an accidental bodily injury provided treatment

occurs within one year from the date of the

accident; or

reconstructive surgery when service is

incidental to or follows surgery resulting from

trauma, infection, or other disease of the

involved part; or

reconstructive surgery, when required

because of a congenital disease or anomaly

of a dependent child that has resulted in a

functional defect; or

reconstructive surgery following a

mastectomy.

services or supplies not listed as covered charges;

expenses incurred as a result of participation in a

felony, riot, or insurrection;

meals, meal preparation, personal comfort or

convenience items, housekeeping services,

custodial care, and protective or companion

services;

any services rendered by a physician or any other

provider of medical services to himself;

•

•

•

–

–

–

–

•

•

•

•

any expenses related to transsexual surgery;

an injury or an illness that is employment related

or that is or could be covered under the Workers’

Compensation Law, occupational disease law, or

similar laws;

where a claim/appeal for Workers’ Compensation

is settled by stipulation or agreement, you cannot

claim benefi ts for the same disability from the

Fund. If benefi ts are paid in error, the Fund must

be reimbursed for any payments to you or your

dependents or providers and all costs of collection,

including attorney’s fees and court costs;

expenses incurred during confi nement in a

hospital owned or operated by the Federal

government, unless required by law;

any charges that you or your dependent are not

legally required to pay, including charges that

would not have been made if no coverage existed;

charges for custodial care, which are institutional

services and supplies, including room and

board, that are designed primarily to assist the

individual in the activities of daily living, rather

than connected to a medical program that can

be expected to improve the individual’s medical

condition;

charges that are not received at the Fund Offi ce,

along with all required supporting information

necessary to process the claim, within 90 days

from date they were incurred;

loss caused by war or any act of war;

to the extent that you or your dependent is in

any fashion paid or entitled to payment for those

expenses by or through a public program;

experimental drugs or substances not approved

by the Food and Drug Administration or drugs

labeled: “Caution limited by Federal law to

investigational use;” or non-FDA approved for

that specifi c purpose;

•

•

•

•

•

•

•

•

•

•


experimental procedures or treatment methods

not approved by the American Medical

Association, the American Dental Association,

or the appropriate medical or dental specialty

society;

services, treatments, or supplies furnished by or

at the direction of the United States government,

any state or other political subdivision thereof, or

any of its agents or agencies;

charges from injuries that occur as a result of

engagement in inherently dangerous activities,

such as automobile racing, motorcycle racing

or other motorized racing equipment, bungee

jumping, boxing or wrestling for profi t, etc.;

to the extent of the exclusions imposed by

BlueCross BlueShield for certain elective surgical

procedure and hospital and extended care facility

admissions;

infertility benefi ts;

early intervention services; and

coverage for any illness or injury determined by the Secretary of Veterans Aff airs to have been incurred in or aggravated during performance of service in the uniformed services (the uniformed services and the Department of Veterans Aff airs

will provide care for service-connected disabilities).

In addition, benefi ts otherwise payable upon

injury to you or your eligible dependent shall be

denied for any injury that results from your or your

dependent’s operation of a motor vehicle while

under the infl uence of alcohol or narcotic drugs,

as defi ned by state law. Benefi ts will also be denied

under this provision when the aff ected automobile

insurance carrier providing motor vehicle insurance

or medical benefi ts denies coverage for injuries due

to the operation of a motor vehicle while the person

is under the infl uence of alcohol or narcotic drugs.

Benefi ts will also be denied for any injury to you or

your eligible dependent when you or the dependent

is operating an uninsured and/or stolen motor

vehicle. Benefi ts shall not be denied for passengers

in the motor vehicle who are otherwise eligible for

benefi ts and who are injured.

•

•

•

•

•

•

•


Plan Facts

Th e chart below provides a fast reference for administrative information about the Health and Welfare Plan.

Legal Name of the Plan Massachusetts Laborers’ Health and Welfare Fund

Plan Number 501

Employer

Identifi cation Number

04-2214296

Plan Type A Qualifi ed Employee Health and Welfare Benefi t Plan that provides medical care, life insurance and accidental death and dismemberment benefi ts to eligible employees and their qualifi ed dependents.

Fiscal Year July 1 — June 30

Plan

Administrator

The Board of Trustees

14 New England Executive ParkSuite 200P.O. Box 4000Burlington, MA 01803-0900

Telephone: 781-272-1000Toll-Free Telephone: 800-342-3792Fax: 781-272-2226Online: www.MLBF.org

Agent for Service of

Legal Process

Service of legal process may be made upon any Fund Trustee.

Type of Administration

of the Plan

Fully funded, self-insured Fund, governed by the Employee Retirement Income Security Act (ERISA) of 1974. collectively bargained, jointly-trusteed labor management trust.

Sources of Financing Payments made to the trust by individual employers under the provisions of the Collective Bargaining or Participation Agreements, participant self-pay contributions, and any income earned from investment of employer and participant self-pay contributions.

Participants and benefi ciaries may receive from the Fund Administrator, upon written request, information as to whether a particular employer or employee organization is a sponsor of the Fund and, if the employer or employee organization is a Fund sponsor, the sponsor’s address.

All monies are used exclusively for providing benefi ts to eligible participants and their dependents, and the paying of all expenses incurred with respect to the operation of the Plan. The Trustees shall review annually the funding status of the Plan.

Th e Board of Trustees

Th e Board of Trustees is made up of an equal number of Employer Representatives and Union Representatives who serve without compensation.

Discretionary Authority of the Board of Trustees and its Designees

In carrying out their respective responsibilities under the Plan, the Board of Trustees, the Fund Administrator and other individuals with delegated responsibility for the administration of the Plan will have discretionary authority to interpret the terms of the Plan and to determine eligibility and

entitlement to Plan benefi ts in accordance with the terms of the Plan. Any interpretation or determina-tion will be given full force and eff ect, unless it can be shown that the interpretation or determination was arbitrary and capricious.

Plan Amendment and Termination

Th e Board of Trustees reserves the right to terminate or amend the Plan including the right to amend or terminate benefi ts or eligibility for any class of participant, when in their sole discretion they determine such action is in the best interest of the Fund and its participants. In addition, the


Plan may be terminated by the Trustees if there is no longer an agreement in eff ect between the Employers and the Union requiring contributions to the Health Fund.

Should the Plan terminate, the Trustees will apply remaining assets of the Fund to continue benefi ts beyond the date of termination. Th e Trustees reserve the right to amend the eligibility rules at the time of termination. In any case, the Trustees will use any remaining assets of the Fund to provide benefi ts and pay administration expenses or otherwise to carry out the purpose of the Plan in accordance with the Plan Document and Trust Agreement until the entire remainder of the Fund has been disbursed.

Collective Bargaining Agreements/Employer ContributionsBenefi ts are provided pursuant to collective bargaining agreements. Th e Fund receives contribu-tions according to collective bargaining agreements between your employer and Massachusetts Laborers’ Health & Welfare Fund. Th ese collective bargaining agreements provide that employers contribute to the Fund on behalf of each covered employee on a specifi ed basis. Certain other employers (such as the Fund Offi ce itself ) may participate in the Plan by signing a participation agreement.

To fi nd out whether a particular employer is contributing to the Fund on behalf of members working under a collective bargaining agreement or a participation agreement and, if so, to which plan of benefi ts the employer is contributing, contact the Fund Offi ce. You can look at the collective bargaining agreements at the Fund Offi ce or get your own copy upon written request to the Fund Offi ce. Th e Fund Offi ce will also provide you with, upon written request, a list of contributing employers.

Organizations Through Which Benefi ts Are ProvidedTh e benefi ts shown in the following chart are fully insured.

FULLY INSURED BENEFITS

Benefi t Identity of Provider

Life insurance, and accidental death and dismemberment insurance

Union Labor Life Insurance Company

Th e benefi ts described in the following chart are paid directly by the Fund itself, or through providers with which the Fund has contracted, pursuant to administrative services agreements, and are not fully insured. Payment of benefi ts is not guaranteed by the Fund, nor does the provider insure or guarantee any of the benefi ts described.

ADMINISTRATIVE SERVICES FORBENEFITS PAID DIRECTLY BY THE FUND

Area of Administration Identity of Provider

Preferred Provider Organiza-tion for providers in the medical plan

BlueCross BlueShield

Locate a Provider:800-810-2583www.BCBS.com

Professional review organization for the medical plan and Preferred Provider Organization for home health care and durable medical equipment

BlueCross BlueShield

Hospital Admission:800-327-6716

Locate a Provider:800-810-2583www.BCBS.com

Professional review organiza-tion and Preferred Provider Organization for treatment of mental health or nervous disorders, alcoholism, and substance abuse

The Wellness Corporation (MAP)

800-522-6763

Preferred Provider Organiza-tion for the dental plan

Delta Dental Plan of Massachusetts

800-872-0500www.deltamass.com

Professional review organization and Preferred Provider Organization for prescription drug benefi ts

Express Scripts

800-467-2006www.express-scripts.com

Preferred Provider Organiza-tion for the vision plan

Davis Vision

800-999-5431www.davisvision.com

No Liability for Practice of MedicineNeither the Fund, nor the Fund Administrator, nor any of their designees are engaged in the practice of medicine, and they do not have any control over any diagnosis, treatment, care or lack thereof, or any health care services provided or delivered to you by any health care provider. Neither the Fund, nor the Fund Administrator, nor any of their designees will have any liability whatsoever for any loss or injury caused to you by any health care provider by reason of negligence, failure to provide care or treatment, or otherwise.


Your ERISA Rights

As a participant in the Massachusetts Laborers’

Health and Welfare Fund, you are entitled to

certain rights and protections under the Employee

Retirement Income Security Act of 1974 (ERISA).

ERISA provides that all Plan participants are

entitled to the following rights:

Receive Information About Your Plan and Benefi ts

You have the right to:

Examine, without charge, at the Fund Offi ce and

at other specifi ed locations, such as worksites and

union halls, all documents governing the Plan.

Th ese documents include insurance contracts

and collective bargaining agreements and a copy

of the latest annual report fi led by the Plan with

the U.S. Department of Labor and available at the

Public Disclosure Room of the Employee Benefi ts

Security Administration.

Obtain, upon written request to the Plan

Administrator, copies of documents governing

the operation of the Plan. Th ese include insurance

contracts and collective bargaining agreements

and copies of the latest annual report and updated

Summary Plan Description. Th e Administrator

may make a reasonable charge for the copies.

Receive a summary of the Plan’s annual fi nancial

report. Th e Plan Administrator is required by law

to furnish each participant with a copy of this

summary annual report.

Continue Group Health Plan Coverage

Continue health care coverage for yourself,

spouse, or dependents if there is a loss of coverage

under the Plan as a result of a qualifying event.

You or your dependents will have to pay for such

coverage. Review this SPD and the documents

•

•

•

•

governing the Plan on the rules governing your

COBRA continuation coverage rights.

Reduction or elimination of exclusionary periods

of coverage for pre-existing conditions under a

group health plan, if you have creditable coverage

from another plan. You should be provided a

HIPAA certifi cate of creditable coverage, free of

charge, from your group health plan or health

insurance issuer when you lose coverage under

the plan, when you become entitled to elect

COBRA continuation coverage, or when your

COBRA continuation coverage ceases, if you

request it before losing coverage or if you request

it up to 24 months after losing coverage. Without

evidence of creditable coverage, you may be

subject to a pre-existing condition exclusion for

12 months (18 months for late enrollees) after

your enrollment date in your coverage.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for Plan participants,

ERISA imposes duties upon the people who are

responsible for the operation of employee benefi t

plans. Th e people who operate your plan, called

“fi duciaries” of the plan, have a duty to do so

prudently and in the interest of you and other Plan

participants and benefi ciaries. No one, including

your employer, your union, or any other person, may

fi re you or otherwise discriminate against you in any

way to prevent you from obtaining a welfare benefi t

or exercising your rights under ERISA.

Enforce Your Rights

If your claim for a welfare benefi t is denied or

ignored, in whole or in part, you have a right

to know why this was done, to obtain copies of

documents relating to the decision without charge,

and to appeal any denial, all within certain time

schedules.

•


Under ERISA, there are steps you can take to

enforce the above rights. For instance, if you request

a copy of Plan documents or the latest annual report

from the Plan and do not receive it within 30 days,

you may fi le suit in a Federal court. In such a case,

the court may require the Plan Administrator to

provide the materials and pay you up to $110 a day

until you receive the materials, unless the materials

were not sent because of reasons beyond the control

of the Plan Administrator.

If you have a claim for benefi ts which is denied

or ignored, in whole or in part, you may fi le suit

in a state or Federal court. In addition, if you

disagree with the Plan’s decision or lack thereof

concerning the qualifi ed status of a medical child

support order, you may fi le suit in Federal court. If

it should happen that Plan fi duciaries misuse the

Plan’s money, or if you are discriminated against for

asserting your rights, you may seek assistance from

the U.S. Department of Labor or you may fi le suit in

a Federal court. Th e court will decide who should

pay court costs and legal fees. If you are successful,

the court may order the person you have sued to

pay these costs and fees. If you lose, the court may

order you to pay these costs and fees, for example, if

it fi nds your claim is frivolous. However, in all cases,

including those described in the above paragraph,

you must fi rst exhaust your administrative remedies

by following the Claims and Appeals Procedures

described in Appendix B before you may fi le suit in

any court.

Assistance With Your Questions

If you have any questions about your plan, you

should contact the Fund Offi ce. If you have any

questions about this statement or about your rights

under ERISA, or if you need assistance in obtaining

documents from the Fund Offi ce, you should

contact the nearest offi ce of the Employee Benefi ts

Security Administration (EBSA), U.S. Department

of Labor, listed in your telephone directory.

Alternatively, you may obtain assistance by calling

EBSA toll-free at 866-444-EBSA (3272) or writing to

the following address:

Division of Technical Assistance and Inquiries

Employee Benefi ts Security Administration

U.S. Department of Labor

200 Constitution Avenue N.W.

Washington, D.C. 20210

You may obtain certain publications about your

rights and responsibilities under ERISA by calling

the publications hotline of EBSA at 800-998-7542 or

contacting the EBSA fi eld offi ce nearest you.

You may also fi nd answers to your plan questions

and a list of EBSA fi eld offi ces at the website

www.dol.gov/ebsa.


Appendix A: Privacy of Health Information

A Federal law known as the Health Insurance

Portability and Accountability Act of 1996 (HIPAA)

requires that the privacy of your personal health

information be protected.

Th e Plan’s Privacy Notice, distributed to all Plan

participants and dependents, explains what

information is considered “Protected Health

Information (PHI).” It also tells you when the Plan

may use or disclose this information, when your

permission or written authorization is required, how

you can get access to your information, and what

actions you can take regarding your information.

PRIVACY NOTICE

Section 1: Purpose of This Notice and Effective DateTHIS NOTICE DESCRIBES HOW MEDICAL

INFORMATION ABOUT YOU MAY BE USED

AND DISCLOSED AND HOW YOU CAN GET

ACCESS TO THIS INFORMATION. PLEASE

REVIEW IT CAREFULLY.

Th is Privacy Notice applies to the Fund Offi ce of the

Massachusetts Laborers’ Health and Welfare Fund

(the “Fund”), and the services that the Fund provides

through BlueCross BlueShield of Massachusetts,

Delta Dental, Express Scripts (formerly known

as NPA/CFI), Davis Vision and other business

associates of the Fund.

Eff ective date: Th e eff ective date of this Notice is

April 14, 2003.

Th is Notice is required by law. Th e Fund is

required by law to take reasonable steps to ensure

the privacy of your personally identifi able health

information and to inform you about:

1. Th e Fund’s uses and disclosures of Protected

Health Information (PHI),

2. Your rights to privacy with respect to your PHI,

3. Th e Fund’s duties with respect to your PHI,

4. Your right to fi le a complaint with the Fund

and with the Secretary of the United States

Department of Health and Human Services

(HHS), and

5. Th e person or offi ce you should contact for

further information about the Fund’s privacy

practices.

Section 2: Your Protected Health Information

Protected Health Information (PHI) Defi ned

Th e term “Protected Health Information” (PHI) includes all individually identifi able health information related to your past, present or future physical or mental health condition or to payment for health care. PHI includes information maintained by the Fund in oral, written, or electronic form.

When the Fund May Disclose Your PHI

Under the law, the Fund may disclose your PHI

without your consent or authorization, or the

opportunity to agree or object, in the following

cases:

For treatment, payment or health care

operations. Th e Fund and its business associates

will use PHI in order to carry out:

1. Treatment,

2. Payment, or

3. Health care operations.

Treatment is the provision, coordination, or

management of health care and related services.

It also includes but is not limited to consulta-

tions and referrals between one or more of your

providers.

•

•


For example, the Fund may disclose to a treating

surgeon the name of your treating physician so

that the surgeon may ask for necessary health

information.

Payment includes but is not limited to actions

to make coverage determinations and payment

(including billing, claims management,

subrogation, plan reimbursement, reviews for

medical necessity and appropriateness of care and

utilization review and preauthorizations).

For example, the Fund may tell a doctor whether

you are eligible for coverage or what percentage

of the bill will be paid by the Fund. If we contract

with third parties to help us with payment

operations, such as a physician that reviews

medical claims, we will also disclose information

to them. Th ese third parties are known as

“business associates.”

Health care operations includes but is not

limited to quality assessment and improvement,

reviewing competence or qualifi cations of health

care professionals, underwriting, premium

rating and other insurance activities relating to

creating or renewing insurance contracts. It also

includes disease management, case management,

conducting or arranging for medical review,

legal services, and auditing functions including

fraud and abuse compliance programs, business

planning and development, business management

and general administrative activities.

For example, the Fund may use information about

your claims to refer you to a disease management

program, a well-pregnancy program, project

future benefi t costs or audit the accuracy of its

claims processing functions.

Disclosure to the Fund’s Trustees. Th e Fund

will also disclose PHI to the Plan Sponsor, the

Board of Trustees of the Massachusetts Laborers’

Health and Welfare Fund, for purposes related to

treatment, payment, and health care operations,

and has amended the Summary Plan Description

to permit this use and disclosure as required

by federal law. For example, we may disclose

information to the Board of Trustees to allow

•

•

•

•

•

•

them to decide an appeal or review a subrogation

claim.

In addition, the Fund may disclose “summary

health information” to the Board of Trustees

for obtaining premium bids or modifying,

amending or terminating the Fund’s group

health plan. Summary information summarizes

the claims history, claims expenses or type of

claims experience by individuals for whom a

Plan Sponsor such as the Board of Trustees has

provided health benefi ts under a group health

plan. Identifying information will be deleted from

summary health information, in accordance with

federal privacy rules.

At your request. If you request it, the Fund is

required to give you access to certain PHI in order

to allow you to inspect and/or copy it.

When required by applicable law.

As required by HHS. Th e Secretary of the

United States Department of Health and Human

Services may require the disclosure of your PHI

to investigate or determine the Fund’s compliance

with the privacy regulations.

Public health purposes. To an authorized public

health authority if required by law or for public

health and safety purposes. PHI may also be

used or disclosed if you have been exposed to a

communicable disease or are at risk of spreading a

disease or condition, if authorized by law.

Domestic violence or abuse situations. When

authorized by law to report information about

abuse, neglect or domestic violence to public

authorities if a reasonable belief exists that you

may be a victim of abuse, neglect or domestic

violence. In such case, the Fund will promptly

inform you that such a disclosure has been or will

be made unless that notice would cause a risk of

serious harm.

Health oversight activities. To a health oversight

agency for oversight activities authorized by law.

Th ese activities include civil, administrative or

criminal investigations, inspections, licensure or

disciplinary actions (for example, to investigate

•

•

•

•

•

•

•


complaints against health care providers)

and other activities necessary for appropriate

oversight of government benefi t programs (for

example, to the Department of Labor).

Legal proceedings. When required for judicial

or administrative proceedings. For example, your

PHI may be disclosed in response to a subpoena

or discovery request that is accompanied by a

court order.

Law enforcement health purposes. When

required for law enforcement purposes (for

example, to report certain types of wounds).

Law enforcement emergency purposes. For

certain law enforcement purposes, including:

1. identifying or locating a suspect, fugitive,

material witness or missing person, and

2. disclosing information about an individual

who is or is suspected to be a victim of a

crime.

Determining cause of death and organ

donation. When required to be given to a

coroner or medical examiner to identify a

deceased person, determine a cause of death or

other authorized duties. We may also disclose

PHI for cadaveric organ, eye or tissue donation

purposes.

Funeral purposes. When required to be given

to funeral directors to carry out their duties with

respect to the decedent.

Research. For research, subject to certain

conditions.

Health or safety threats. When, consistent

with applicable law and standards of ethical

conduct, the Fund in good faith believes the use

or disclosure is necessary to prevent or lessen

a serious and imminent threat to the health or

safety of a person or the public and the disclosure

is to a person reasonably able to prevent or lessen

the threat, including the target of the threat.

Workers’ Compensation programs. When

authorized by and to the extent necessary to

comply with Workers’ Compensation or other

similar programs established by law.

•

•

•

•

•

•

•

•

Except as otherwise indicated in this notice, uses

and disclosures will be made only with your written

authorization subject to your right to revoke your

authorization.

When the Disclosure of Your PHI Requires Your Written Authorization

Although the Fund does not routinely obtain

psychotherapy notes, it must generally obtain your

written authorization before the Fund will use or

disclose psychotherapy notes about you. However,

the Fund may use and disclose such notes when

needed by the Fund to defend itself against litigation

fi led by you.

Psychotherapy notes are separately fi led notes

about your conversations with your mental health

professional during a counseling session. Th ey

do not include summary information about your

mental health treatment.

Th e Fund may provide health information for the

purpose of evaluating and processing a claim for

Accident and Sickness benefi ts; however, the Fund

will obtain your written authorization before it

will use or disclose any health information for this

purpose.

When You Can Object and Prevent the Fund from Using or Disclosing PHI

Disclosure of your PHI to family members, other

relatives, your close personal friends, and any other

person you choose is allowed under federal law if:

Th e information is directly relevant to the family

or friend’s involvement with your care or payment

for that care, and

You have either agreed to the disclosure or have

been given an opportunity to object and have not

objected.

Other Uses or Disclosures

Th e Fund may contact you to provide you with

information about treatment alternatives or other

health-related benefi ts and services that may be of

interest to you.

•

•


Section 3: Your Individual Privacy Rights

You May Request Restrictions on PHI Uses and Disclosures

You may request the Fund to:

1. Restrict the uses and disclosures of your PHI

to carry out treatment, payment or health care

operations, or

2. Restrict uses and disclosures to family

members, relatives, friends or other persons

identifi ed by you who are involved in your

care.

Th e Fund, however, is not required to agree to your

request.

You or your personal representative will be required

to complete a form to request restrictions on uses

and disclosures of your PHI. Make such requests to:

Privacy Offi cial

Massachusetts Laborers’ Health and Welfare Fund

14 New England Executive Park, Suite 200

Burlington, MA 01803

(781) 272-1000 or (800) 342-3792

You May Request Confi dential Communications

Th e Fund will accommodate an individual’s

reasonable request to receive communications of

PHI by alternative means or at alternative locations

where the request includes a statement that

disclosure could endanger the individual.


to complete a form to request restrictions on uses

and disclosures of your PHI. Make such requests

to the Fund’s Privacy Offi cial (at the address listed

above).

You May Inspect and Copy PHI

You have a right to inspect and obtain a copy of your

PHI contained in a “designated record set,” for as

long as the Fund maintains the PHI.

Th e Fund must provide the requested information

within 30 days if the information is maintained

on site or within 60 days if the information is

maintained off site. A single 30-day extension is

allowed if the Fund is unable to comply with the

deadline.


to complete a form to request access to the PHI in

your designated record set. A reasonable fee may be

charged. Requests for access to PHI should be made

to the Fund’s Privacy Offi cial (at the address listed at

the left).

If access is denied, you or your personal representa-

tive will be provided with a written denial setting

forth the basis for the denial, a description of

how you may exercise your review rights and a

description of how you may complain to the Fund

and HHS.

Designated Record Set: includes your medical

records and billing records that are maintained

by or for a covered health care provider. Records

include enrollment, payment, billing, claims

adjudication and case or medical management

record systems maintained by or for a health plan

or other information used in whole or in part by or

for the covered entity to make decisions about you.

Information used for quality control or peer review

analyses and not used to make decisions about you

is not included.

You Have the Right to Amend Your PHI

You have the right to request that the Fund amend

your PHI or a record about you in a designated

record set for as long as the PHI is maintained in the

designated record set subject to certain exceptions.

See the Fund’s Right to Amend Policy (available on

request from the Fund’s Privacy Offi cial) for a list of

exceptions.

Th e Fund has 60 days after receiving your request

to act on it. Th e Fund is allowed a single 30-day

extension if the Fund is unable to comply with the

60-day deadline. If the Fund denied your request

in whole or part, the Fund must provide you with

a written denial that explains the basis for the

decision. You or your personal representative may

then submit a written statement disagreeing with


the denial and have that statement included with

any future disclosures of that PHI.

You should make your request to amend PHI to

the Fund’s Privacy Offi cial (at the address listed on

page 54). You or your personal representative will be

required to complete a form to request amendment

of the PHI.

You Have the Right to Receive an Accounting of the Fund’s PHI Disclosures

At your request, the Fund will also provide you with

an accounting of certain disclosures by the Fund

of your PHI. We do not have to provide you with

an accounting of disclosures related to treatment,

payment, or health care operations, or disclosures

made to you or authorized by you in writing. See the

Fund’s Accounting for Disclosure Policy (available

on request from the Fund’s Privacy Offi cial) for the

complete list of disclosures for which an accounting

is not required.

Th e Fund has 60 days to provide the accounting. Th e

Fund is allowed an additional 30 days if the Fund

gives you a written statement of the reasons for the

delay and the date by which the accounting will be

provided.

If you request more than one accounting within a

12-month period, the Fund will charge a reasonable,

cost-based fee for each subsequent accounting.

You Have the Right to Receive a Paper Copy of Th is Notice Upon Request

To obtain a paper copy of this Notice, contact the Fund’s

Privacy Offi cial (at the address listed on page 54).

Your Personal Representative

You may exercise your rights through a personal

representative. Your personal representative will be

required to produce evidence of authority to act on

your behalf before the personal representative will

be given access to your PHI or be allowed to take

any action for you. Proof of such authority will be

a completed, signed and approved Appointment of

Personal Representative form. You may obtain this

form by calling the Fund Offi ce.

Th e Fund retains discretion to deny access to

your PHI to a personal representative to provide

protection to those vulnerable people who depend

on others to exercise their rights under these rules

and who may be subject to abuse or neglect.

Th e Fund will recognize certain individuals as

personal representatives without you having to

complete an Appointment of Personal Representa-

tive form. For example, the Fund will automatically

consider a spouse, a parent of a member, or an

adult child (age 18 or over) of a member to be the

personal representative of an individual covered

by the plan. In addition, the Fund will consider a

parent or guardian as the personal representative

of a dependent covered child, unless applicable

law requires otherwise. A spouse, parent or adult

child may act on an individual’s behalf, including

requesting access to their PHI. Spouses and

unemancipated minors may, however, request that

the Fund restrict information that goes to family

members as described above at the beginning of

Section 3 of this Notice.

You should also review the Fund’s Policy and

Procedure for the Recognition of Personal Represen-

tatives (available upon request from the Fund’s

Privacy Offi cial) for a more complete description of

the circumstances where the Fund will automatically

consider an individual to be a personal representa-

tive for purposes of exercising your rights under this

Privacy Notice.

Section 4: The Fund’s Duties

Maintaining Your Privacy

Th e Fund is required by law to maintain the privacy

of your PHI and to provide you and your eligible

dependents with notice of its legal duties and

privacy practices.

Th is notice is eff ective beginning on April 14, 2003

and the Fund is required to comply with the terms of

this notice. However, the Fund reserves the right to

change its privacy practices and to apply the changes

to any PHI received or maintained by the Fund

prior to that date. If a privacy practice is changed,


a revised version of this notice will be provided to

you and to all past and present participants and

benefi ciaries for whom the Fund still maintains PHI.

Th e Privacy Notice will be provided via fi rst class

mail to all named participants. Any other person,

including dependents of named participants, may

receive a copy upon request.

Any revised version of this notice will be distributed

within 60 days of the eff ective date of any material

change to:

1. Th e uses or disclosures of PHI,

2. Your individual rights,

3. Th e duties of the Fund, or

4. Other privacy practices stated in this notice.

Disclosing Only the Minimum Necessary Protected Health Information

When using or disclosing PHI or when requesting

PHI from another covered entity, the Fund will

make reasonable eff orts not to use, disclose or

request more than the minimum amount of PHI

necessary to accomplish the intended purpose of the

use, disclosure or request, taking into consideration

practical and technological limitations.

However, the minimum necessary standard will not

apply in the following situations:

1. Disclosures to or requests by a health care

provider for treatment,

2. Uses or disclosures made to you,

3. Disclosures made to the Secretary of the

United States Department of Health and

Human Services pursuant to its enforcement

activities under HIPAA,

4. Uses or disclosures required by law, and

5. Uses or disclosures required for the Fund’s

compliance with the HIPAA privacy

regulations.

Th is notice does not apply to information that has

been de-identifi ed. De-identifi ed information is

information that:

1. Does not identify you, and

2. With respect to which there is no reasonable

basis to believe that the information can be

used to identify you.

Section 5: Your Right to File a Complaint with the Fund or the HHS SecretaryIf you believe that your privacy rights have been

violated, you may fi le a complaint with the Fund in

care of the following Privacy Offi cial (at the address

listed above).

You may also fi le a complaint with:

Secretary of the U.S. Department

of Health and Human Services

Hubert H. Humphrey Building

200 Independence Avenue S.W.

Washington, D.C. 20201

Th e Fund will not retaliate against you for fi ling a

complaint.

Section 6: If You Need More InformationIf you have any questions regarding this notice or

the subjects addressed in it, you may contact the

Privacy Offi cial at the Fund Offi ce.

Section 7: ConclusionPHI use and disclosure by the Fund is regulated

by the federal Health Insurance Portability and

Accountability Act, known as HIPAA. You may fi nd

these rules at 45 Code of Federal Regulations Parts

160 and 164. Th is notice attempts to summarize

the regulations. Th e regulations will supersede

this notice if there is any discrepancy between the

information in this notice and the regulations.


Appendix B: Claims and Appeals Procedures

Th is section describes the procedures for fi ling claims for benefi ts from the Massachusetts Laborers’ Health and Welfare Fund. It also describes the procedure for you to follow if your claim is denied in whole or in part and you wish to appeal the decision.

Discussed below are the various types of claims associated with Plan benefi ts, procedures for fi ling claims, and the steps involved in appealing a decision with which you disagree. Th e processing times mentioned in the discussion are summarized

in the charts at the end of the discussion.

Use of an Authorized RepresentativeAn authorized representative, such as your spouse, may complete a claim form for you if you are unable to complete the form yourself and have designated the individual to act on your behalf. A form can be obtained from the Fund Offi ce to designate an authorized representative. Th e Plan may request additional information to verify that this person is authorized to act on your behalf.

A health care professional with knowledge of your medical condition may act as an authorized representative in connection with the “urgent care claims” discussed below without your having to

designate an authorized representative.

Types of ClaimsTh ere are six types of claims applicable to the benefi ts described in this section. Four of them have

to do with health care:

Pre-service claims: A pre-service claim is a request for authorization of care or treatment that requires approval in whole or in part before the care or treatment is obtained (also called “pre-authorization” or “pre-certifi cation”).

Under this Plan, prior approval of services is

required for the following:

non-emergency hospital admissions, other than stays of a certain length following childbirth, or admission to a skilled nursing facility;

•

–

surgery;

gastric bypass surgery;

complementary medical care (biofeedback, homeopathy, massage therapy, naturopathy, nutrition, oriental medicine);

hospice or home health care;

inpatient or outpatient treatment for a mental or nervous condition, alcoholism, or substance abuse;

durable medical equipment; and

certain prescription drugs (see page 25 for information on how to obtain a list of drugs that require pre-authorization).

If you fail to get prior approval for these services,

penalties could range from $250 (for an

inpatient admission) to complete denial of the

claim (for all other services requiring pre-

authorizations).

Urgent care claims: Your request for a required pre-authorization will be considered an urgent care claim if applying the time frames allowed for a pre-service claim (generally 15 to 30 days for a request submitted with suffi cient information) would:

seriously jeopardize your life or health or your ability to regain maximum function; or

in the opinion of a physician with knowledge of your medical condition, subject you to severe pain that could not be adequately managed without the care or treatment that is the subject of the claim.

Th e claims examiner, applying the judgment

of a prudent layperson who possesses an

average knowledge of health and medicine, will

determine whether your claim is an urgent claim.

Alternatively, if a physician with knowledge of

your medical condition determines your claim is

an urgent claim and notifi es the claims examiner

in writing, it will be treated as an urgent claim.

Concurrent claim: A concurrent claim is a decision that is reconsidered after an initial

–––

––

––

•

–

–

•


approval was made, resulting in a reduction, termination, or extension of the previously approved benefi t. (For example, an inpatient hospital stay originally pre-approved for fi ve days is subjected to concurrent review at three days to determine if the full fi ve days are appropriate.) In this situation, a decision to reduce, terminate, or extend treatment is made concurrently with the provision of treatment. Th is category also includes requests by you or your provider to extend care or treatment approved under an urgent claim.

Post-service claims: Any other type of health care claim is considered a post-service claim—for example, a claim submitted for payment after health services and treatment have been obtained.

Th e other two types of benefi t claims under this Plan are as follows:

Disability claim: A disability claim is a claim for weekly accident and sickness benefi ts or a claim that requires a fi nding that you are totally disabled (for example, to receive the disability extension described on page 22).

Claims for life insurance and accidental death and dismemberment benefi ts (called “life and AD&D claims” in the text that follows).

What is NOT a “Claim”

Th e following are not considered claims and are thus not subject to the requirements and time frames described in this section:

Casual inquiries about benefi ts or the circumstances under which benefi ts might be paid;

A request for an advance determination regarding the Plan’s coverage of a treatment or service that does not require pre-authorization (such as the recommended requests for pre-treatment estimates for dental services); and

A prescription you present to a pharmacy to be fi lled.

•

•

•

•

•

•

Urgent care claims should not be confused with emergency care or treatment at an urgent care facility, which do not require pre-authorization. An urgent care claim is a request for a required pre-authorization (a “pre-service claim”) that needs to be handled on an expedited basis.

Filing a Claim

A claim for benefi ts is a request for Plan benefi ts

made in accordance with the Plan’s reasonable

claims procedures. Th e method used to fi le a claim

will depend on the type of claim:

Pre-service claims:

Pre-service claims for medical services

other than treatment of a mental or nervous

condition, alcoholism, or substance abuse:

You or your doctor should call BlueCross

BlueShield at 800-327-6716.

Pre-service claims for treatment a mental or

nervous condition, alcoholism, or substance

abuse: Call the Member Assistance Program

(MAP) at 800-522-6763.

Pre-service claims for prescription drug

benefi ts: Your doctor should call Express

Scripts at 800-417-8164 or fax a letter of

medical necessity to 800-357-9577.

Urgent care claims: Urgent claims (claims for

pre-authorization that need to be handled on an

expedited basis) should be directed to the same

parties mentioned above for pre-service claims.

Post-service claims: Claim forms for post-service

health care claims must be completed in full, and

an itemized bill or bills must be attached.

Post-service health care claims for medical and

vision care benefi ts (necessary if you use a non-

network provider) should be sent to the Fund

Offi ce at the following address: Massachusetts

Laborers’ Health and Welfare Fund, 14 New

England Executive Park, Suite 200, P.O. Box 4000,

Burlington, MA 01803-0900. You can obtain a

claim form from the Fund Offi ce; alternatively,

your hospital, doctor, or other health care

provider may use a standard billing form, such as

a UB 92 or HCFA 1500, and fi le it directly with the

Fund on your behalf. For specifi c information on

fi lling out claim forms for medical plan benefi ts,

see page 23.

Claims for prescription drug benefi ts (a claim

for reimbursement if you use a non-network

pharmacy) should be submitted directly to

•

–

–

–

•

•


Express Scripts, P.O. Box 390873, Bloomington,

MN 55439-0873. Forms are available from Express

Scripts or the Fund Offi ce.

Claims for dental benefi ts (necessary if you use

a non-network dentist) should be sent to Delta

Dental Plan of Massachusetts, P.O. Box 9695,

Boston, MA 02114. You can download a claim

form from the Web site www.deltamass.com or

use a universal claim form.

Disability, life and AD&D claims: Disability

claims and life and AD&D claims should be

sent to the Fund Offi ce at the following address:

Massachusetts Laborers’ Health and Welfare

Fund, 14 New England Executive Park, Suite

200, P.O. Box 4000, Burlington, MA 01803-0900.

Th e Fund Offi ce will forward claims for life and

AD&D benefi ts to the insurance company.

When Claims Must Be FiledYour claim will be considered to have been fi led on the fi rst business day it is received by the applicable claims evaluator mentioned under “Filing a Claim.”

Pre-service and urgent claims must be fi led before services are obtained.

Dental claims must be fi led within one year of the date when you receive the service. You must submit all other health care claims within 90 days of when expenses are incurred (or, it that is not reasonably possible, no later than one year after charges were incurred).

Claims for disability benefi ts must be submitted within 90 days of the onset of disability.

Claims for life and AD&D benefi ts must be fi led

within 90 days of the loss.

Notifi cation Th at Your Pre-Service or Urgent Claim Has Not Been Properly Filed

An example of an improperly fi led claim is one

that is not addressed to a person or organizational

unit customarily responsible for handling benefi t

matters.

If your pre-service claim has been improperly

fi led, you will be notifi ed as soon as possible but no

•

later than fi ve days after receipt of the claim of the

proper procedures to be followed in fi ling a claim.

If your urgent care claim has been improperly

fi led, you will be notifi ed as soon as possible but no

later than 24 hours after receipt of the claim of the

proper procedures to be followed in fi ling a claim.

You will receive notice that you have improperly

fi led your claim only if the claim includes your

name, your specifi c condition or symptom, and a

specifi c treatment, service, or product for which

approval is requested. Unless the claim is re-fi led

properly, it will not constitute a claim.

Timing of Initial Claims DecisionsA determination on your claim will be made within

the following time frames:

Pre-service claims: If your pre-service health

care claim has been properly fi led, you will

be notifi ed of a decision within 15 days from

the date your claim is fi led, unless additional

time is needed. Th e time for response may be

extended by up to 15 days if necessary due to

matters beyond the control of the applicable

claims evaluator. If an extension is necessary,

you will be notifi ed before the end of the initial

15-day period of the circumstances requiring

the extension and the date by which the claims

evaluator expects to make a decision.

If an extension is needed because the claims

evaluator needs additional information from

you, the claims evaluator will notify you as

soon as possible, but no later than 15 days after

receipt of the claim, of the specifi c information

necessary to complete the claim. In that case

you and/or your doctor will have 45 days from

receipt of the notifi cation to respond. During

the period in which you are allowed to supply

additional information, the normal period for

making a decision on the claim will be suspended.

Th e deadline is suspended from the date of the

extension notice until either the 45 days have

passed or you respond to the request (whichever

is earlier). Th e claims evaluator then has 15

days to make a decision and notify you of the

•


determination. If the information is not provided

within the 45 days allowed, your claim will be

denied.

Urgent care claim: You will be notifi ed of a

determination by telephone as soon as possible,

taking into account the exigencies of your

situation, but no later than 72 hours after

receipt of the claim by the claims evaluator. Th e

determination will also be confi rmed in writing.

If your urgent care claim is received without

suffi cient information to determine whether or

to what extent benefi ts are covered or payable,

the claims evaluator will notify you as soon as

possible, but no later than 24 hours after receipt

of the claim, of the specifi c information necessary

to complete the claim. You and/or your doctor

must respond to this request within 48 hours.

During the period in which you are allowed

to supply additional information, the normal

period for making a decision on the claim will

be suspended. Th e deadline is suspended from

the date of the extension notice until either the

two business days have passed or you respond

to the request (whichever is earlier). Notice of a

decision will be provided no later than 48 hours

after the receipt of the required information. If

the information is not provided within the two

business days allowed, your claim will be denied.

Concurrent claim: A reconsideration that

involves the termination or reduction of payment

for a treatment in progress (other than by Plan

amendment or termination) will be made by

the claims evaluator as soon as possible, but in

any event early enough to allow you to have an

appeal decided before the benefi t is reduced or

terminated.

A request by you to extend treatment approved

under an urgent claim will be acted upon by the

claims evaluator within 24 hours of receipt of

the claim, provided the claim is received at least

24 hours prior to the expiration of the approved

treatment.

Post-service claims: Ordinarily, you will be

notifi ed of the decision on your post-service

health care claim within 30 days of the date the

•

•

•

claims evaluator receives the claim. Th is period

may be extended one time by up to 15 days if the

extension is necessary due to matters beyond the

control of the claims evaluator. If an extension

is necessary, you will be notifi ed before the end

of the initial 30-day period of the circumstances

requiring the extension and the date by which the

claims evaluator expects to make a decision.

If an extension is needed because the claims

evaluator needs additional information from

you, the claims evaluator will notify you as

soon as possible, but no later than 30 days after

receipt of the claim, of the specifi c information

necessary to complete the claim. You and/or

your doctor or dentist will have 45 days from






extension notice until either 45 days have passed

or the date you respond to the request (whichever

is earlier). Th e claims evaluator then has 15 days

to make a decision on your post-service claim and

notify you of the determination. If the information

is not provided within the 45 days allowed, your

claim will be denied.

Disability claims: Th e Fund Offi ce will ordinarily

make a decision on the claim and notify you

of the decision within 45 days of receipt of

the claim. Th is period may be extended by up

to 30 days if the extension is necessary due to

matters beyond the control of the Fund Offi ce.

If an extension is necessary, you will be notifi ed

before the end of the initial 45-day period of the

circumstances requiring the extension and the

date by which the Fund Offi ce expects to make

a decision. A decision will then be made within

30 days of when the Fund Offi ce notifi es you of

the delay. Th e period for making a decision may

be extended an additional 30 days, provided the

Fund Offi ce notifi es you, prior to the expiration

of the fi rst 30-day extension period, of the


date as of which the Fund Offi ce expects to render

a decision. Th e notifi cation of the extension

•


Th e specifi c reason(s) for the determination;

Reference to the specifi c Plan provision(s) on

which the determination is based;

A description of any additional material or

information necessary to perfect the claim, and an

explanation of why the material or information is

necessary;

A description of the appeals procedures

(including voluntary appeals, if any) and

applicable time limits;

A statement of your right to bring a civil action

under ERISA Section 502(a) following an adverse

benefi t determination on review;

If an internal rule, guideline, or protocol was

relied upon in deciding your claim, either a

statement that you will receive a copy of the rule

or a statement that it is available upon request at

no charge; and

If the determination was based on the absence

of medical necessity or the treatment’s being

experimental or investigational or other similar

exclusion, either a statement that you will

receive an explanation of the scientifi c or clinical

judgment for the determination applying the

terms of the Plan to your claim or a statement

that it is available upon request at no charge.

Appeal Process for Denied ClaimsInformation on appeals for dental benefi ts is omitted

from the discussion that follows. For dental claims,

you must exhaust the appeals process with Delta

Dental fi rst. (See the brochure from Delta Dental.)

You may then fi le a voluntary appeal with the Plan’s

Board of Trustees.

If your claim is denied in whole or in part, or if you

disagree with the decision made on a claim, you may

ask for a review (appeal the decision).

You must submit your appeal to the Fund Offi ce by

the applicable deadline.

within 180 days after you receive the notice

of denial for a claim involving health care or

disability (or, in the case of a concurrent claim,

••

•

•

•

•

•

•

will specifi cally provide an explanation of the

standards on which entitlement to a benefi t

is based, the unresolved issues that prevent

a decision on the claim, and the additional

information needed from you to resolve the

issues.

If an extension is needed because the Fund Offi ce

needs additional information from you, the

Fund Offi ce will notify you as soon as possible,

but no later than 45 days after receipt of the

claim, of the specifi c information necessary to

complete the claim. You will have 45 days from






extension notice until either 45 days have passed

or the date you respond to the request (whichever

is earlier). Th e Fund Offi ce then has 30 days to

make a decision on your claim and notify you

of the determination. If the information is not

provided within the 45 days allowed, your claim

will be denied.

For disability claims, the Plan reserves the right

to have a Physician examine you (at the Plan’s

expense) as often as is reasonable while a claim for

benefi ts is pending.

Life and AD&D claims: Th e insurance company

will ordinarily make a decision on a claim for

life or AD&D benefi ts within 90 days of when it

receives the claim. Th is period may be extended

by up to 90 days if the extension is necessary due

to matters beyond the control of the insurance

company. If an extension is necessary, you will be

notifi ed before the end of the initial 90-day period

of the circumstances requiring the extension and

the date by which the insurance company expects

to make a decision.

Notice of a Denied Claim

You will be provided with written notice of a denial

of a claim (whether denied in whole or in part). Th is

notice will include:

•


within a reasonable time, given the exigencies of

your situation); or

within 60 days after you receive the notice of

denial for life and AD&D claims.

Requests for review of claims other than urgent care

claims must be in writing. Appeals involving urgent

care claims may be made orally by calling the Fund

Offi ce at 781-272-1000 or 800-342-3792 during

normal business hours.

Th e appeal process works as follows:

Pre-Service, Urgent Care, and Concurrent Claim Appeals

For pre-service, urgent care, and concurrent

claim appeals, there is one level of appeal. A

subcommittee consisting of the Union Trustee

Chairman or his or her alternate, the Employer

Trustee Secretary-Treasurer or his or her alternate,

and the Fund Administrator will review pre-service,

urgent care, and concurrent claim appeals. In

certain circumstances such as urgent care claim

appeals where medical conditions exist that require

an expedited review process, appeals may be made

orally via telephone.

Post-Service and Disability Claim Appeals

For post-service and disability claims appeals, there

is a two-level appeal process. Th e fi rst level of appeal

will consist of a review by the Fund Administrator.

If the appeal is denied, you have the right to a

second level consisting of review by the full Board of

Trustees. Requests for second-level appeals must be

made within 60 days after the fi rst appeal is denied.

Life Insurance and AD&D Claim Appeals

For life insurance and AD&D claim appeals, there

is one level of appeal at the Fund Offi ce. Th e Fund

Offi ce will review the claim appeal.

Information To Which You Are Entitled

You have the right to review documents relevant

to your claim. A document, record or other

information is relevant if it was relied upon by

the Plan in making the decision; it was submitted,

•

considered or generated (regardless of whether

it was relied upon in making the decision);

it demonstrates compliance with the Plan’s

administrative processes for ensuring consistent

decision-making; or it constitutes a statement

of Plan policy regarding the denied treatment or

service.

Upon request, you will be provided with the identifi -

cation of medical or vocational experts, if any, who

gave advice to the Plan on your claim, without

regard to whether their advice was relied upon in

deciding your claim.

A diff erent person will review your claim than the

one who originally denied the claim or the previous

appeal. Th e reviewer will not give deference to

the previous adverse benefi t determinations. Th e

decision will be made on the basis of the record,

including such additional documents and comments

that may be submitted by you.

If your claim was denied on the basis of a medical judgment (such as a determination that the treatment or service was not medically necessary, or was investigational or experimental), a health care professional who has appropriate training and experience in a relevant fi eld of medicine will be consulted.

Timing of Notice of Decision on AppealPre-Service Claims: You will be sent a notice of

decision on review within 30 days of receipt of

the appeal by the Fund Offi ce.

Urgent Care Claims: You will be notifi ed of a

decision on your appeal, either orally or in writing

(or both) within 72 hours of receipt of the appeal

by the Fund Offi ce.

Post-Service Claims: For fi rst-level appeals,

a decision will be made on the appeal within

30 days of receipt of the appeal by the Fund

Administrator. For second level appeals, decisions

will be made at the next regularly scheduled

meeting of the Board of Trustees following

receipt of your request for review. However, if

your request for review is received within 30

days of the next regularly scheduled meeting,

•

•

•


your request for review will be considered at the

second regularly scheduled meeting following

receipt of your request. In special circumstances,

a delay until the third regularly scheduled meeting

following receipt of your request for review may

be necessary. You will be advised in writing in

advance if this extension will be necessary. Once

a decision on review of your claim has been

reached, the Fund Offi ce will give you written

notice of the decision as soon as possible, but no

later than fi ve days after the decision has been

reached.

Disability Claims: For fi rst-level disability

claim appeals a decision will be made by

the Fund Administrator within 45 days of

receipt of the appeal at the Fund Offi ce. If the

Fund Administrator determines that special

circumstances require an extension of time, then

you will receive a written notice of the extension

before the end of the 45-day period. Th e notice

will include the reasons required for the extension

and the approximate date the Plan expects to

make a decision.

For second level appeals, decisions will be made

at the next regularly scheduled meeting of the

Board of Trustees following receipt of your

request for review. However, if your request

for review is received within 30 days of the

next regularly scheduled meeting, your request

for review will be considered at the second

regularly scheduled meeting following receipt of

your request. In special circumstances, a delay

until the third regularly scheduled meeting

following receipt of your request for review may

be necessary. You will be advised in writing in

advance if this extension will be necessary. Once

a decision on review of your claim has been

reached, the Fund Offi ce will give you written

notice of the decision as soon as possible, but no

later than fi ve days after the decision has been

reached.

Life and AD&D claims: Decisions will ordinarily

be made within 60 days of receipt of appeal by

the Fund Administrator. Th e period for making

a decision may be extended by up to 60 days,

•

•

provided the Fund Administrator notifi es you,

prior to the expiration of the fi rst 60 days, of the


date as of which the Fund Administrator expects

to render a decision.

Notice of Decision on Review

Th e decision on any review of your claim will be

given to you in writing. Th e notice of a denial of a

claim on review will state:

Th e specifi c reason(s) for the determination;

Reference to the specifi c Plan provision(s) on

which the determination is based;

A statement that you are entitled to receive

reasonable access to and copies of all documents

relevant to your claim, upon request and free of

charge;

A statement of your right to bring a civil action

under ERISA Section 502(a) following an adverse

benefi t determination on review;

If an internal rule, guideline or protocol was relied

upon by the Plan, either a statement that you will

receive either a copy of the rule or a statement

that it is available upon request at no charge;

If the determination was based on medical

necessity, the treatment’s being experimental

or investigational, or other similar exclusion,

either an explanation of the scientifi c or clinical

judgment for the determination applying the

terms of the Plan to your claim or a statement

that it is available upon request at no charge.

Limitation on When a Lawsuit May be StartedYou may not start a lawsuit to obtain benefi ts until

after you have:

exhausted all levels of appeal and fi nal decisions

have been reached on those appeals; or

the appropriate time frame described above has

elapsed since you fi led a request for review and

you have not received a fi nal decision or notice

that an extension will be necessary to reach a fi nal

decision.

••

•

•

•

•

•

•


Pre-Service Claims Urgent Claims Concurrent Claims Post-Service Claims

Claims examiner makes initial determination (provided all necessary information is submitted)

Within 15 days of claim’s receipt (can be extended for another 15 days)

Within 72 hours of claim’s receipt

In time for you to appeal before a reduction or terminationWithin 24 hours of request for extension of urgent care

Within 30 days of claim’s receipt(can be extended for another 15 days)

Claims examiner notifi es you claim has been improperly fi led

Within fi ve days of claim’s receipt


Not applicable Not applicable

Claims examiner requests additional information

Within 15 days of claim’s receipt


Not applicable Within 30 days of claim’s receipt

You respond to request for information

Within 45 days of request Within 48 hours of request Not applicable Within 45 days of request

Claims examiner makes determination after requesting additional information

Within 15 days of your response or expiration of the time allowed

Within 48 hours of your response or expiration of the time allowed

Not applicable Within 15 days of your response or expiration of the time allowed

You make request for appeal

Within 180 days of receiving notice of denial


Within a reasonable time for your situation


Appropriate authority makes decision on appeal

Within 30 days of receiving your request for appeal

Within 72 hours of receiving your request for appeal

Within a reasonable time for type of care decision

First level: Within 30 days of receiving your request for appeal

Second level: At next regular Board meeting at least 30 days after receiving your request for appeal (or no later than third such meeting)

Th e law also permits you to pursue your remedies

under section 502(a) of the Employee Retirement

Income Security Act without exhausting these appeal

procedures if the Plan has failed to follow them.

No lawsuit to recover Plan benefi ts may be started

more than 15 months after the date of loss (that is,

the date you incurred the expense you are seeking to

have the Plan pay) upon which the lawsuit is based.

Because the Plan grants its fi duciaries discretionary

authority to determine eligibility for benefi ts

and to construe the terms of the Plan, the issue

in a lawsuit will be limited to whether or not the

Board of Trustees (or its delegates, including the

subcommittee for Urgent Care, Pre-Service and

Concurrent Claims) acted arbitrarily or capriciously

in making its determination.

MAXIMUM TIMES FOR PROCESSING OF HEALTH CARE CLAIMS(Times are suspended during waits for additional information requested of you)


MAXIMUM TIMES FOR PROCESSING OF DISABILITY AND LIFE AND AD&D CLAIMS(Times are suspended during waits for additional information requested of you)

Disability Claims Life and AD&D Claims

Fund Offi ce or insurance company makes initial determination (provided all necessary information is submitted)

Within 45 days of claim’s receipt (can be extended for another 30 days and an additional 30 days after that)

Within 90 days of claim’s receipt(can be extended for another 90 days)

Fund Offi ce requests additional information Within 45 days of claim’s receipt Not applicable

You respond to request for information Within 45 days of request Not applicable

Fund Offi ce makes determination after requesting additional information

Within 30 days of your response or expiration of the time allowed

Not applicable

You make request for appeal Within 180 days of receiving notice of denial Within 60 days of receiving notice of denial

Board of Trustees makes decision on appeal

First level: Within 45 days of receiving notice of denial (can be extended)Second level: At next regular Board meeting at least 30 days after receiving your request for appeal (or no later than third such meeting)

Within 60 days of receipt of your request for appeal (can be extended another 60 days)


Appendix C: Glossary

Th ese are some of the terms used in your booklet. Some other terms are described where they are used. Please read these terms carefully. Th ey may help you to better understand your benefi ts.

Ambulatory Surgical Facility means any public or private establishment that:

is licensed as such by the state,

has an organized medical staff of physicians,

has permanent facilities,

is equipped and operated primarily for the purpose of performing surgical procedures, and

provides continuous physician and registered graduate nursing services, whenever a patient is in the facility.

Ambulatory surgical facility does not include physicians’ or dentists’ offi ces or any facilities whose primary purpose is the termination of pregnancy or a facility that provides services or other accommoda-tions for patients to stay overnight.

Complications of Pregnancy means:

conditions requiring hospital stays when the pregnancy is not terminated and the diagnosis is distinct from pregnancy but is adversely aff ected by pregnancy or caused by pregnancy; or

non-elective cesarean section, ectopic pregnancy that is terminated, and spontaneous termination of pregnancy that occurs during a period of gestation in which a viable birth is not possible.

Covered Medical Expenses means the reasonable and customary charges that are incurred for the medically necessary treatment of conditions that are covered under this Plan.

Custodial Care means all services and supplies, including room and board, that are provided, whether you are disabled or not, primarily to assist in the activities of daily living. Such services and supplies are custodial care without regard to the practitioner or provider by whom or by which they are prescribed, recommended, or performed. Some examples of such services are: help in walking, getting in and out of bed, bathing, dressing, eating, taking medicine.

Dentist means a person authorized by law and duly licensed to practice dentistry.

••••

•

•

•

Experimental procedure means:

any medical procedure, equipment, treatment or course of treatment, or drug or medicine that is meant to investigate and is limited to research, or is not approved by a sanctioning body, i.e., Federal Drug Administration, American Medical Association, or American Dental Association;

techniques that are restricted to use at centers that are capable of carrying out disciplined clinical eff orts and scientifi c studies;

procedures that are not proven in an objective way to have therapeutic value or benefi t; and

any procedure or treatment whose eff ectiveness is medically questionable.

Extended Care Facility means an institution, or a distinct part of an institution, that

is operated pursuant to law and is primarily engaged in providing, for compensation from its patients, skilled nursing care for patients who require medical care on account of Injury or sickness;

provides 24 hour a day nursing service under the supervision of a full-time employee who is either a doctor or a registered nurse;

maintains clinical records on all patients;

provides for having a physician available to furnish necessary medical care in case of emergency; and

provides appropriate methods and procedures for the dispensing and administering of drugs and biologicals.

In no event, will “extended care facility” include any institution that is a hospital or that is primarily for the care of mental illness, drug addiction, alcoholism, or tuberculosis or that is primarily engaged in providing domiciliary, custodial, or educational care or care for the aged. Benefi ts are payable under the hospital plan provision.

Hospital means an institution that:

is primarily engaged in providing, by or under the supervision of physicians, inpatient diagnostic and therapeutic services for the diagnosis, treatment, and rehabilitation of injured, disabled, or sick persons;

maintains clinical records on all patients;

•

•

•

•

•

•

••

•

•

•

67 | Massachusetts Laborers’ Health and Welfare Fund67 | Massachusetts Laborers’ Health and Welfare Fund

has bylaws in eff ect with respect to its staff of physicians;

has a requirement that every patient be under the care of a physician;

provides a 24 hour nursing service rendered or supervised by a registered professional nurse;

is licensed pursuant to any state or agency of the state responsible for licensing hospitals; and

has accreditation under one of the programs of the Joint Commission on Accreditation of Hospitals.

Unless specifi cally provided, the term “hospital” does not include any institution, or part thereof, that is used principally as a rest facility, nursing facility, convalescent facility, or facility for the aged, nor does it mean any institution that makes a charge that you or your dependents are not required to pay. Licensed institutions used principally for the care and treatment of mental and nervous disorders or alcoholism and substance abuse will be included under the defi nition of “hospital.”

Illness means any sickness, disorder, or disease that is not employment related. Pregnancy is treated in the same manner as an illness under this Plan for you or an eligible dependent.

Injury means physical damage to your or your dependent’s body caused by purely accidental means, independent of all other causes. Only injuries that are not employment related except as provided on page 45 or automobile accident-related are considered for benefi ts under this Plan, except under the life insurance and accidental death and dismemberment benefi ts.

Medically Necessary means any service, supply, treatment, or hospital confi nement that is essential for the diagnosis or treatment of the injury or illness for which it is prescribed or performed; meets generally accepted standards of medical practice; and is ordered by a physician. If not medically necessary, no benefi ts are payable.

Th e fact that a physician may prescribe, recommend, or approve a service or supply does not, of itself, make it medically necessary or make the expense a covered charge.

Medicare means the health insurance program set forth in Parts A and B, Title XVIII of the Social Security Act of 1965, as amended.

Nurse means a Registered or Licensed Practical Nurse, or a Licensed Vocational Nurse who has the right to use the abbreviation “R.N.,” “L.P.N.,” or “L.V.N.”

•

•

•

•

•

Obstetrical Procedure means one of the obstetrical procedures listed below:

an abdominal operation for extra uterine or ectopic pregnancy;

the delivery of a child(ren) by means of a cesarean section;

the delivery of a child(ren) by means other than a cesarean section; or

services in connection with miscarriage, with or without dilation and curettage.

Th e term “prenatal care” means care rendered in the physician’s offi ce, prior to termination of pregnancy. Th e term “postnatal care” means care rendered in the physician’s offi ce during the 90-day period following termination of pregnancy. Postnatal care does not include any care rendered to the newborn child or children.

Pharmacy means a licensed establishment where prescription drugs are dispensed by a pharmacist.

Physician means a duly licensed doctor of medicine authorized to perform medical or surgical services within the lawful scope of his practice and also includes any other health care provider or allied practitioner as mandated by state law.

Reasonable and Customary Charges means the amount normally charged for similar services and supplies that does not exceed the amount ordinarily charged for comparable services and supplies in the locality where the patient resides. In determining whether charges are reasonable and customary, due consideration will be given to the nature and severity of the condition being treated and any medical complications or unusual circumstances that require additional time, skill, or experience.

Skilled Nursing Care and Services means one or more of the professional services and care that may be rendered by a registered professional nurse or by a licensed practical nurse under the direction of a registered professional nurse.

Totally Disabled means that

you’re prevented, because of injury or disease from engaging in your customary occupation and are performing no work of any kind for pay or profi t; or

you’re prevented, because of injury or disease, from engaging in substantially all the normal activities of a person of like age and sex in good health.

•

•

•

•

•

•


The Board of Trustees

Th e names and addresses of the Health and Welfare Fund Trustees as of the date this

Summary Plan Description was issued are as follows:

Th e Board of Trustees consists of an equal number of Union and Employer representatives

who serve without compensation.

Union Trustees Employer Trustees

Louis A. Mandarini, Jr.

Chairman

Laborers’ Local Union #2235 Highland AvenueMalden, MA 02148

Tel: 781-321-6616/6626Fax: 781-321-6662

John A. Farina

Secretary/Treasurer

James Farina Corp.120 Adams StreetP. O. Box 600269Newton, MA 02460

Tel: 617-332-8650Fax: 617-527-5380

Joseph Bonfi glio

Co-Chairman

Laborers’ Local Union #151238 Main StreetCambridge, MA 02142

Tel: 617-876-8081Fax: 617-492-0490

Richard McCourt

Co-Secretary/Treasurer

McCourt Construction Company60 “K” StreetSouth Boston, MA 02127

Tel: 617-269-2330Fax: 617-269-2313

Thomas Troy

Laborers’ Local Union #1421623 Main StreetWoburn, MA 01801Tel: 781-933-1401Fax: 781-933-1403

Thomas J. Gunning

Building Trades Employers Assoc.150 Grossman Drive, Suite 313Braintree, MA 02184

Tel: 781-849-3220Fax: 781-849-3223

Douglas J. Watson

ME, NH, VT District Council500 Market Street, 3APortsmouth, NH 03801

Tel: 603-431-3181Fax: 603-433-9369

William Sullivan

Daniel O’Connell’s Sons, Inc.P. O. Box 267Holyoke, MA 01041

Tel: 413-540-1449Fax: 413-534-2902

massachusetts laborers’ health and welfare fund...delta dental— questions about dental beneﬁ...

Documents